Exceptional patients and communication in cancer care-are we missing another survival factor?

OBJECTIVE: There is increased awareness of the issue of exceptional survival beyond expectations among cancer patients with poor prognosis, and researchers are starting to look closely at this phenomenon. In this study, we explored the perceptions of these "exceptional patients" as to their understanding and insight into their unusual experience. METHODS: We used a qualitative approach consisting of in-depth, open-ended interviews with exceptional patients in two locations, Texas and Israel, from 2007 to 2014. The interviews were audio-recorded and qualitatively analyzed, and gave rise to illness narratives entailing detailed descriptions of patients experience over the course of their disease and treatment. A qualitative content analysis focusing on contextual meaning was utilized. RESULTS: Twenty-nine patients participated in our study. The mean years since diagnosis was 9.55 years (range, 4-23 years). All patients had received conventional treatment, including surgery, chemotherapy, and radiation therapy. One of the prevailing themes in these interviews was related to the patient-doctor relationship. Most participants mentioned that the support they received from one or more physicians was a crucial factor for their exceptional survival. CONCLUSION: The significance of patient-doctor relationship in cancer survival requires further research. This research is especially important as it adds to the current trend of patient centered care and points to the added value of relationship between health providers and patients. This relationship, as perceived by these exceptional patients, can be a factor that adds to improved survival in cancer care.

Living outliers: experiences, insights and narratives of exceptional survivors of incurable cancer.

AIM: Unexplained prolonged survival given a diagnosis of incurable advanced cancer is a puzzling phenomenon that recently has attracted more scientific research. The purpose of this study was to add to the understanding of how exceptional patients perceive and explain their unusual experience. METHODS: We recruited patients for interviews from a population registry, patients with advanced lung or pancreatic malignancy who experienced exceptional survival. RESULTS & CONCLUSION: In total, 15 participants were interviewed. The main recurrent themes in most of the interviews were patient-doctor communication, family support and the patient's proactive attitude. In this study, patients attribute their longevity to relationships with their doctor and their family - not the type of treatment they received. Further research on this phenomenon is needed.

[Evidence-based clinical database--rational use saves time].

During the last decade, the production of medical information has doubled every 14 months. It is predicted that information will double at an even faster rate. This dramatic rate of changing medical knowledge presents a challenge for physicians to keep up to date. Physicians are usually eager for the latest medical information. The late British epidemiologist, Archie Cochrane, developed a relatively new approach using up-to-date medical information. His approach integrates individual clinical expertise with the best available external clinical evidence from systematic research. Through this method new information is located, identified and its significance evaluated. If the new information has been proven to be reliable and relevant, it is integrated into existing information systems to be used by physicians all over the world. This approach is called evidence-based medicine. This review will summarize the four leading clinical databases which are evidence based medicine oriented: Dynamed, Cochrane Library, Trip database and Attract, and short presentation of the best evidence based medicine "secondary literature".

The e-patient: a survey of israeli primary care physicians' responses to patients' use of online information during the consultation.

BACKGROUND: The Internet has transformed the patient-physician relationship by empowering patients with information. Because physicians are no longer the primary gatekeepers of medical information, shared decision making is now emerging as the hallmark of the patient-physician relationship. OBJECTIVES: To assess the reactions of primary care physicians to encounters in which patients present information obtained from the Internet (e-patients) and to examine the influence of the physicians' personal and demographic characteristics on their degree of satisfaction with e-patients. METHODS: A questionnaire was developed to assess physicians' attitudes to e-patients, their knowledge and utilization of the Internet, and their personal and professional characteristics. Family physicians in central Israel were interviewed by telephone and in person at a continuing medical education course. RESULTS: Of the 100 physicians contacted by phone, 93 responded to the telephone interviews and 50 physicians responded to the questionnaire in person. There was an 85% response rate. The mean age of respondents was 49 years. Most physicians were born in Israel, with a mean seniority of 22 years. Most had graduated in Eastern Europe, were not board certified and were employees of one of the four health management organizations in Israel. Most physicians responded positively when data from the Internet were presented to them by patients (81%). A number of respondents expressed discomfort in such situations (23%). No association was found between physicians' satisfaction in relationships with patients and comfort with data from the Internet presented by patients. CONCLUSIONS: Physicians in this sample responded favorably to patients bringing information obtained online to the consultation. Though it may be difficult to generalize findings from a convenience sample, Israeli family physicians appear to have accepted internet use by patients.

[Validation of an international infrastructure and management set of quality indicators for Israeli primary care].

BACKGROUND: Adequate premises, equipment and organization of care are prerequisites for good primary care. The lack of a generally accepted systematic framework for practice management contributes to clinical outcome variations as well as inequalities in health care delivery. OBJECTIVE: To validate, localize and assess an internationally validated method for practice assessment in primary care in Israel. METHODS: The international tool contained 6 domains, 171 indicators and 470 items in 32 different aspects of primary health care provision. The instrument was translated into Hebrew. The major assessment in Israel was performed in 30 practices of Clalit Health Services by practice visits of 2 independent observers who completed check lists, structured interviews with the management staff of the clinic, work satisfaction questionnaires of the clinic staff and satisfaction questionnaires to patients at 30 clinics. The data was processed and analysed by SPSS. Frequency distribution and descriptive statistics were computed for all questions. Factor and reliability analysis were used to reduce the remaining items to a reduced number of indicators. OUTCOMES: From the initial 171 indicators and 470 items, we have managed to downsize the process of evaluation to a feasible size of 57 indicators and 142 items which have been proved as discriminating between the practices on an international level. The Israeli assessment downsized the number of locally discriminating indicators to 50. CONCLUSIONS/RECOMMENDATIONS: The resulting set of indicators is good and valid for improving the organization and management of general practices. On a national Israeli level there is need for further validation, which will include all the Israeli providers.

Factors in the doctor-patient relationship that accentuate physicians' hurt feelings when patients terminate the relationship with them.

OBJECTIVE: The present study explores the emotional effect of the injury experienced by physician's, as a consequence of a patient's termination of their relationship. METHODS: A vignette study using different scenarios describing a patient who switched to another doctor was distributed to 119 family physicians. A three-way ANCOVA analysis was employed. Additionally, physicians' answered an open question asking of situations that elicited negative emotions. RESULTS: The quantitative results indicated that termination of the relationship by a "high status" patient and/or after a long duration is more emotionally hurtful than termination by a "lower status" patient after a brief relationship. The results of the open question provided an additional insight into the emotional impact of the doctor's hurt feelings on the doctor-patient relationship. CONCLUSIONS: The severity and consequences of the emotional injury experienced by physicians when patients decide to transfer to another physician are influenced by factors related to the patient, physician and the relationship between them. PRACTICE IMPLICATIONS: We discuss the implications of our results on the understanding of the emotional injury and consequent impaired function and possible "burn-out" in physicians and explore the possibility of educating doctors to heightened awareness and consequently enhanced ability to cope with such situations.

Aggregation of qualitative studies--From theory to practice: Patient priorities and family medicine/general practice evaluations.

OBJECTIVE: Aggregation (i.e., meta-ethnography or meta-synthesis) of qualitative studies remains relatively rare and controversial. We have attempted this procedure within an investigation of patient priorities and evaluations of primary care in order to triangulate an instrument development process as well as explore associated dilemmas. METHODS: The procedures included a literature search of qualitative research on patient priorities and evaluations and creation of a framework for quality assessment of retrieved papers. The tool for the evaluation of quality in qualitative studies was piloted, refined, and applied to the retrieved literature. The articles were equally distributed between two teams in random fashion, and inter-rater agreement calculated. Finally, we formulated and applied a strategy for aggregation of data from included papers that allowed comparison to a systematic review of quantitative studies on the topic. RESULTS: Thirty-seven articles met inclusion criteria. Twenty-four of these articles were of sufficient quality to be included in the qualitative aggregation. Inter-rater agreement ranged from 0.22 to 0.77 and 0.38 to 0.60 for pair and assessor comparisons, respectively. The aggregation strategy enabled synthesis within sub-categories of the heterogeneous papers. CONCLUSIONS: We have devised a modestly reliable instrument to assess the quality of qualitative work. The procedure for quality assessment and aggregation appears to be both feasible and potentially useful, though both theoretical and practical problems underline the need for further refinement prior to widespread utilization of this approach. PRACTICE IMPLICATIONS: An instrument to assess the quality of qualitative work within the context of aggregation efforts is described. Calculating inter-rater reliability in this framework can support future quality assessments. A method of breaking a heterogeneous collection of included papers into sub-categories to enable aggregation of qualitative studies is applied and demonstrates its feasibility and potential usefulness.

The LBP patient perception scale: a new predictor of LBP episode outcomes among primary care patients.

OBJECTIVE: To describe a new tool designed to capture patients' perception of their low back pain (LBP) episodes-the patient perception scale (PPS) and test its ability to predict episode outcomes. METHODS: Thirty-two family physicians recruited 526 low back pain patients during an office visit. Physicians completed a short questionnaire at the index visit, which included both their assessments of patients' patient perception scale (PPS-doc) and contact information. Patients were then interviewed by telephone within 2 weeks after the index visit, with follow-up telephone contacts at 2, 4, 8 and 12 months. The patient perception scale as reported by the physician (PPS-doc) and patient (PPS-pt), each constituent question, and different combinations were analyzed for their ability to predict patient outcomes. RESULTS: Patients' responses (PPS-pt) proved predictive for all outcome items. PPS-doc was much less predictive. Measures of patient centeredness did not perform well in this study. CONCLUSION: By using a short scale based on the patient's perception of pain (PPS-pt), it is possible to predict adverse outcomes of a low back pain episode. The patient perception scale should be evaluated further and perhaps combined with other instruments for targeting care and chronicity prevention efforts in low back pain. PRACTICE IMPLICATIONS: The PPS-pt could potentially be used as part of the standard initial patient evaluation of new LBP patients, as a proxy for "yellow flags" (markers of psychosocial risk) where a positive score might be the equivalent to high-risk identification. The apparent advantage of this scale is its brevity and simplicity of administration. The separation, through this scale of pain episodes into simple and complex LBP might be a useful tool for helping direct resources and avoiding chronicity.

Promoting lifestyle self-awareness among the medical team by the use of an integrated teaching approach: a primary care experience.

OBJECTIVES: Healthy lifestyle is recommended in clinical guidelines for the prevention and treatment of chronic diseases such as cardiovascular disease and diabetes. Research previously identified a gap between lifestyle recommendations and their implementation in clinical practice. In this paper, we describe a pilot educational program aimed to promote providers' awareness of their own lifestyles, and to explore whether increased personal awareness enhances providers' willingness to engage in lifestyle-change discussion with patients. METHODS: Two primary-care urban clinics in Northern Israel participated in the program, which consisted of a series of six biweekly educational sessions, each lasting 2-4 hours. Each session included both knowledge-based and experiential learning based on complementary medicine modalities. Surveys at the end of the program and a year later provided the program evaluation. RESULTS: Thirty-five personnel participated in the program. Thirteen (13) of the 20 participants (65%) reported an attitude change regarding eating habits after the program. At 1-year follow up, 24 of the 27 respondents (89%) stated that they were more aware of their eating habits and of their physical activity compared with precourse status. Twenty-three (23) of 27 respondents (85%) stated that after the program they were better prepared to initiate a conversation with their patients about lifestyle change. CONCLUSIONS: An integrated educational approach based on knowledge-based and complementary and alternative medicine experiential modalities, aimed to facilitate self-awareness, may enhance learners' attitude change. The findings demonstrate readiness of learners to reexamine their lifestyles. Increased self-awareness helped participants to make a positive attitude change regarding eating habits and physical activity and was associated with participants' increased engagement in lifestyle-change discussions with patients. The teaching approach had longstanding effect, noted in the one-year follow-up.

The challenge of using the low back pain guidelines: a qualitative research.

PURPOSE: Current low back pain (LBP) clinical guidelines have helped to summarize the scientific evidence and research, but have failed to provide tools and guide family physicians (FPs). The purpose of this study is to identify barriers and facilitators for the implementation of LBP guidelines from family FPs' perspective. METHODS: A qualitative focus group study of FPs in the north of Israel. Purposeful sampling was used to recruit participants, all of them board-certified FPs. Four focus groups were created, and discussions were taped, transcribed and analysed for major themes. RESULTS: Focus groups findings have expanded the understanding of the intellectual and mental challenges faced by Israeli FPs caring for LBP patients and highlighted the many obstacles to implementing LBP guidelines. Physicians' decision-making, pertaining to LBP, functions on three levels simultaneously: the physicians' agenda based on familiarity with the guidelines; their need to remain grounded in the context of the specific patient-doctor relationship; and the constraints and demands of the physician's workplace, medical system and environment. CONCLUSIONS: Despite an overall positive attitude towards LBP guideline implementation, FPs found it hard to come to terms with the conflicting dimensions of LBP patient care. The patient-doctor interaction determined the outcome of the encounter, whether it complied with the guidelines and whether the encounter leads to a healing process or to a vicious circle of unnecessary utilization of services.

[Percutaneous discectomy and intradiscal radiofrequency thermocoagulation for low back pain: evaluation according to the best available evidence].

Within the framework of evidence-based medicine, high quality randomized trials and systematic reviews are needed for new medical treatment. Clinicians should conscientiously, explicitly and judiciously use the best current evidence in making decisions about the care of individual patients. This paper summarizes the best available evidence from systematic reviews and randomized controlled trials concerning two minimally invasive procedures: percutaneous discectomy and percutaneous intradiscal radiofrequency thermocoagulation. Percutaneous discectomy is a minimally invasive surgical procedure that treats contained, herniated discs. Specific procedures within the class include: manual percutaneous lumbar discectomy, Automated percutaneous lumbar discectomy (APLD) laser discectomy and nucleoplasty percutaneous intradiscal radiofrequency thermocoagulation is a procedure that allows the controlled delivery of heat to the intervertebral disc via an electrode or coil. Results of systematic reviews were retrieved from four leading evidence-based databases: the National Institute for Clinical Excellence--NICE, which is an independent organization responsible for providing national guidance on treatments, the Cochrane Library, which is the largest library world-wide for systematic reviews and randomized controlled trials, the Center for Review and Dissemination (CRD) at the University of York, which undertakes reviews of research about the effects of interventions in health and social care and finally, a search via Medline. The results from those systematic reviews and randomized trials shows that, at present, unless or until better scientific evidence is available, automated percutaneous discectomy and laser discectomy should be regarded as research techniques. Radiofrequency denervation can relieve pain from neck joints, but may not relieve pain originating from lumbar discs, and its impact on low-back joint pain is uncertain.

[The importance of sexual orientation in the medical consultation].

Gay, lesbian, bisexual and transgender (GLBT) patients have unique and different health needs other then those of the heterosexual patient. Although a significant proportion of the population is gay or lesbian, physicians receive little formal training about homosexuality, and the unique health care needs of these patients are often ignored. GLBT patients may have higher rates of depression, suicide attempts, alcoholism, and certain cancers, sexual transmitted and cardiovascular disease. One of the most significant medical risks of these populations is avoidance of routine health care and dissatisfaction due to fear of stigmatization by the medical community. Youth GBLT patients are particularly vulnerable to internal and external pressures, resulting in higher rates of substance and alcohol abuse, suicide, and homelessness. Declining health and loneliness may trouble older GBLT patients, who generally view themselves more positively. Physicians can improve the health care of GBLT patients and their families by maintaining a non-homophobic attitude toward these patients, distinguishing sexual behavior from sexual identity, communicating with gender-neutral terms, and maintaining awareness of how their own attitude affects clinical judgment. Scant research exists with regard to the best ways to teach medical students about the special challenge GBLT patients face. However, the recommendation is to integrate such teaching throughout the entire medical school curriculum. This article includes a summary of the medical literature for the GBLT patients' health care needs and suggests strategies for enhancing the care for this population, as well as incorporating it during the medical education.

The Effect of Combined Aspirin and Clopidogrel Treatment on Cancer Incidence.

BACKGROUND: Multiple studies have shown an association between aspirin treatment and a reduction in newly diagnosed cancer. Conversely, there are conflicting clinical and laboratory data on the effect of combined clopidogrel and aspirin therapy on cancer incidence, including analyses suggesting an increased cancer risk. No large-scale cohort study has been performed to address this issue in a heterogeneous real-world scenario. We investigated the effect of clopidogrel and aspirin on cancer incidence compared with aspirin alone and no antiplatelet therapy. METHODS: A population-based historical cohort study of subjects aged ≥50 years covered by Clalit Health Services, an Israeli health maintenance organization, was performed. Patients treated with the newer antiplatelet drugs, prasugrel or ticagrelor, which, like clopidogrel, inhibit adenosine diphosphate receptors, and those with prior cancer were excluded. Prescription records of antiplatelet medication were retrieved. RESULTS: The cohort included 183,912 subjects diagnosed with 21,974 cancer cases based upon the International Classification of Diseases, Ninth Revision. Dual aspirin and clopidogrel was prescribed in 9.6%, while 49% received aspirin alone and 41% used neither. Compared with nonusers, there was a lower risk of cancer in subjects exposed to aspirin with (hazard ratio [HR] 0.46; 95% confidence interval [CI], 0.44-0.49) or without clopidogrel (HR 0.54; 95% CI, 0.52-0.56), on long-term follow-up. Combined treatment was associated with a lower cancer risk than the aspirin-only group (HR 0.92; 95% CI, 0.86-0.97). CONCLUSIONS: Dual clopidogrel and aspirin treatment is safe regarding the cancer risk. This study generates the hypothesis that clopidogrel may reduce cancer incidence.

An approach to teaching primary care physicians how to integrate complementary medicine into their daily practices: a pilot study.

This paper describes a pilot educational approach to integration of complementary and alternative medicine (CAM) into the daily routine of primary care practice. Twelve (12) family practice residents and specialists were assigned to develop an integrative treatment program geared to address the needs of their own patients. In the process, participants were asked to formulate treatment plans by searching resources to find appropriate CAM modalities and consult with CAM practitioners. The effectiveness of the educational process was assessed by questionnaires. The researchers found that providing a short course in advanced integrative medicine improves physician ability to better formulate an individualized treatment plan. This approach of teaching has long-standing results, as noted with a 2-year follow-up evaluation.

Eating attitudes among adolescents.

BACKGROUND: Israeli youth lead 27 western countries in dieting. The prevalence of eating disorders has been rising in the last 30 years, causing social problems and medical complications. OBJECTIVES: To examine the prevalence of eating disorders among high school students in a region in northern Israel (Misgav) and to examine the relationship between the parents' employment status and the subject's eating disorder. METHODS: A structured questionnaire was administered to collect demographic data. The short version of the Eating Attitudes Test (EAT-26) was used to evaluate the subject's attitudes toward and preoccupation with food, dieting, eating, physical appearance, and personal control over eating. RESULTS: Of 360 students approached, 283 (78%) completed the self-report EAT-26. One of every 5 females and one in every 20 males had an abnormal eating attitude. The rate of pathologic EAT-26 results, 20.8%, falls within the high range of similar community-based samples of female adolescents. There were no differences in EAT-26 score between students with an employed or unemployed mother; however, there was a trend for higher EAT-26 scores among those whose father was unemployed (21.4% vs. 12.7%, chi2 = 0.14). CONCLUSIONS: The findings support our hypothesis of a relatively high rate of abnormal eating attitudes (as reflected by high EAT-26 score) in this population. Another possible risk factor is having an unemployed father, which warrants further research and attention. Our next step is to introduce an intervention program in the school and to study its effect.

[Complementary medicine research in Israel between the years 1994-2004].

Alternative and complementary medicine (CAM) is gaining the attention of the medical academic community due to increased public use and ongoing concern of efficacy, safety and quality of CAM treatments. The aim of this work was to review the scope of research that was performed in Israel during the past 10 years. We detected 91 works that focus on clinical research: RCT's, pilot studies, comparative studies, surveys of prevalence & patterns of use, and the attitudes of the medical establishment and of medical students. The results of this work indicate considerable progress in the research of CAM within medical establishments in Israel. We believe that future research will benefit from an upgrading of quality of research that will further focus on cost-effectiveness as well as on possible adverse effects of CAM. This goal can be achieved through appropriate research training of MD's and CAM therapists, and by governmental funding of the research.

[Recording of risk factors and preventive pharmaceutical therapy among ischemic heart disease patients in family practice during the years 1993-1998].

The review of international literature yielded unsatisfactory performance of guidelines for secondary prevention of cardiovascular diseases. This study aimed to evaluate records of the implementation of guidelines published in 1995, for the treatment and follow-up of patients after myocardial infarction in family medicine. In a retrospective sectional cohort study we identified all the patients with previous myocardial infarction in the practices of 6 family physicians, with an overall total of 97 patients. All data was gathered from manual medical records. The quality of care was evaluated according to follow-up indicators such as performance of blood pressure measurement, LDL cholesterol tests and according to secondary prevention indicators such as: treatment with aspirin, beta blockers and statins. In the cohort of 97 patients, 20.6% had diabetes, 53.6% had hypertension and 88.7% performed blood pressure follow-up, 100% cholesterol and fasting glucose tests, and 86.6% LDL cholesterol tests. Of the eligible patients, 98% received aspirin, 81% received beta-blockers and 76.2% were treated with statins. The target LDL cholesterol was not achieved by 66.7% of the patients. During the years 1993-1998 the quality of secondary prevention in the study was better than findings reported in international publications in corresponding years. However, the treatment of hypercholesterolemia should be improved.

The Ecology of Medical Care Among Israeli Military Aviators.

BACKGROUND: The ecology of medical care model has been used in various populations with varying results. We aimed to apply this model in the population of Israeli Air Force (IAF) aviators. METHODS: An anonymous questionnaire was presented to all Israeli Air Force aviators during their mandatory yearly check-up over 1 yr starting on November 26th, 2012. The questionnaire contained items on demographic, personal, and military details, as well as items on the presence of clinical symptoms, and various health care contacts in the previous month. We assessed the differences between career and reserve personnel using a X2 test. RESULTS: There were 325 aviators who completed the questionnaire (2 women, 132 reserves). Clinical symptoms were reported by 62.5% of the responders. Over half (52.6%) had any health care encounter: 23.7% with a dentist, 17.9% with non-MD therapists, 12.6% with a specialist, and 11.7% with a primary physician. A significant difference between reserve and career personnel was found only in primary care visits. Out of the aviators who reported having clinical symptoms, 70.9% did not visit a physician. Of those who did not seek medical care, 42.4% reported that the symptoms were viewed as unimportant, 41% thought they would disappear by themselves, 40.3% could not find time for treatment. CONCLUSIONS: Aviators in the IAF have similar rate of clinical symptoms as in other unselected populations. Those who report symptoms usually do not visit a physician for treatment. When they do seek advice it is mostly from non-MD practitioners.Gordon B, Levy Y, Yemini T, Carmon E, Erlich Y, Hermoni D. The ecology of medical care among Israeli military aviators. Aerosp Med Hum Perform. 2016; 87(12):1036-1040.

The role of the patient care team in elderly people decision on influenza vaccination.

Understanding the elderly decision-making process on influenza vaccination is important in developing appropriate strategies to increase uptake. Our objective was to explore the decision making process on influenza vaccination among an elderly population. Prospective documentation of baseline data and vaccination status of elderly primary care patients was followed by a telephone survey 5 months later to explore their decision making process. Baseline data and vaccination status were documented on 1313 patients out of whom 51% received the influenza vaccine. Telephone survey was attempted in all of them and eventually 950 (72.4%) were interviewed. When members of the patient care team (PCT) provided information on the vaccine, were consulted about it and were actively involved in the vaccination decision, each resulted in a significantly higher (p<0.0001) rate of immunization. After logistic regression analysis, only consultation with PCT remained significantly associated with higher (p<0.0001) immunization rate. Our findings emphasize the central role of the PCT in improving uptake of the influenza vaccine and point at the stages where change can, and should, be made.

[A review of the evidence based smoking cessation interventions delivered by the family physician].

Smoking is one of the most preventable causes of morbidity and mortality resulting in almost 10,000 deaths each year in Israel. Since tobacco-related disease is preventable, efforts to promote cessation in patients who smoke should be a routine step in preventive primary care measures. In Israel, 26% of the adult population smoke. Within this group, a third want to quit but only two percent succeed in abstaining from smoking for a whole year. Family physicians are in an ideal position to facilitate patients' attempts to quit smoking: 70% of smoking patients report that firm, supportive messages from their family physician can act as an important motivating factor to quit smoking. The updated Clinical Practice Guidelines from the US Public Health Service recommend that family physicians should opportunistically advise smokers to stop smoking during routine consultation, encourage and assist smokers in the use of nicotine replacement therapies or bupropion and refer smokers to professional behavioral or psychological counselors specializing in smoking cessation. Most physicians rank smoking as the most important behavior affecting health, but few physicians are confident in their own ability to help their patients stop smoking. In this review the authors present several evidence-based strategies that were found to be helpful in promoting smoking cessation when delivered by general practitioners. The power of the physician's advice, first and second line agents, behavioral counseling and stage based interventions, are all discussed in detail.