Unpopular medical specialties: exploring the concept that "the customer knows best".

BACKGROUND: Healthcare systems often face shortages of certain medical specialists due to lack of interest among medical students. We questioned a common "one solution fits all" approach to this problem which involves monetary incentives to lure students to these specialties. Instead, we used the marketing principle the "consumer knows best" to explore ways of elucidating the reasons and proposing solutions for such shortages. METHODS: A convenience sample of Israeli 6th-year medical students and interns completed questionnaires to determine why they thought three specialties (geriatrics, anesthesiology, emergency medicine) were unpopular and their ideas on increasing their appeal. RESULTS: 119 6th-year students and 84 interns completed questionnaires. Geriatrics was reported having a problematic patient population; not being interesting and challenging; and not considered prestigious by colleagues and the populace. This contrasts with emergency medicine which, although considered prestigious, has difficult working conditions both during and after residency accompanied by much pressure at work. Although, improvements in lifestyle and remuneration were thought by students and interns as possibly making these specialties more attractive, reducing the pressure at work and decreasing on-call obligations were designated by the students/interns as ways to increase emergency medicine's and anesthesiology's appeal. Half the students replied that anesthesiology would be more appealing if work was in shifts (< 16 h), while 60% replied so for emergency medicine and only 18% for geriatrics. 90% of students reported that control over lifestyle would make emergency medicine more attractive while 55% and 48% replied positively for anesthesiology and geriatrics, respectively. CONCLUSIONS: Using the concept "consumer knows best" provided additional insight into the specialty selection process. Students/interns have specialty-specific opinions as to why some specialties are unpopular. Their ideas about attracting more students to these specialties were also specialty-dependent, i.e. "one solution does not fit all". These observations render problematic a single solution aimed at ameliorating the workforce shortages of multiple specialties. Instead, these results advocate a differential approach wherein the lack of appeal of each unpopular specialty is analyzed individually and the students'/interns' (the "consumers") ideas sought resulting in solutions tailored to address each specialty's lack of attractiveness. TRIAL REGISTRATION: None.

[FALSE POSITIVE AMBULATORY BLOOD PRESSURE MONITORING: CHALLENGES IN ACCURATE DIAGNOSIS OF MASKED UNCONTROLLED HYPERTENSION.]

INTRODUCTION: Masked uncontrolled hypertension (MUCH), describes a mismatch between normal office measurements and out of range home blood pressure. Although it is often underdiagnosed, it is associated with high risk of hypertensive complications and morbidity. Ambulatory blood pressure monitoring (ABPM) is defined as the "reference standard" for diagnosing hypertension and is especially effective in cases of MUCH. Although there are many references on the advantages of ABPM, very few studies consider its limitations. To the best of our knowledge, false-positive ABPM has not previously been reported. We report a case in which a positive ABPM result obtained during a stressful situation became normal after being repeated in a non-stressful time. We, therefore, suggest implementing routine pre-test assessment of stressful situations in patients undergoing ABPM. This strategy will lead to improving the accuracy of ABPM and avoiding false-positive results.

Strengthening general practice/family medicine in Europe-advice from professionals from 30 European countries.

BACKGROUND: Substantial variations are still to be found in the strength of general practice/family medicine (GP/FM) across Europe regarding governance, workforce competence and performance, as well as academic development and position. Governments are encouraged by the WHO to secure high quality primary health care to their population, a necessity for reaching the goal "Health for all". The present study aimed at investigating the opinions of council members of the European Academy of Teachers in General Practice (EURACT) on necessary actions to strengthen the position of GP/FM in their country. METHODS: The study used a mixed methods exploratory sequential design. EURACT representatives from 32 European countries first participated in brain-storming on how to strengthen GP/FM in Europe. Later, representatives from 37 countries were asked to individually score the relevance of the proposed actions for their country on a 9-point Likert scale. They were also asked to evaluate the status of GP/FM in their country on four dimensions. RESULTS: Respondents from 30 European countries returned complete questionnaires. To build and secure GP/FM as an academic discipline comprising teaching and research was seen as essential, regardless the present status of GP/FM in the respective country. To build GP/FM as a specialty on the same level as other specialties was seen as important in countries where GP/FM held a strong or medium strong position. The importance of common learning objectives and a defined bibliography were stated by respondents from countries where GP/FM presently has a weak position. CONCLUSIONS: In order to strengthen GP/FM throughout Europe, EURACT and other professional organizations must establish common goals and share expertise between countries. To influence decision makers through information on cost-effectiveness of a GP/FM-based health care system is also important.

Using medical specialty and selection criteria clusters to study specialty selection by Israeli medical students.

BACKGROUND: During their final year of medical school, Israeli students must consider which specialty to choose for residency. Based on the vocational counseling literature we presumed that choices are made by selecting from a cluster of related specialties while considering professional and socio-economic issues. METHODS: Questionnaires distributed to final-year medical students at two Israeli medical schools ascertained inclinations toward various medical specialties and the importance of various selection criteria. Analysis focused on seven specialties where >20% of students reported they had positive inclinations. For each such specialty, the specialty and selection criteria query were compared using unpaired two-tailed Student's t-tests to determine differences between students with positive inclinations toward the specialty with those not so inclined. These data were placed in tables, with the significant differences highlighted to facilitate visual recognition of cluster patterns. RESULTS: Completed questionnaires were obtained from 317 of 455 students. Students often had positive inclinations toward more than one specialty (specialty clusters) associated with a group of selection criteria (selection criteria clusters). For example, interest in internal medicine was clustered with interest in internal medicine subspecialties, cardiology and research. Furthermore, there was a "reciprocal" aspect to some specialty cluster patterns. For example, those interested in internal medicine had little interest in surgical specialties. Selection criteria clusters revealed occupational interests and socio-environmental factors associated with the specialty clusters. For example, family medicine, which clustered with pediatrics and psychiatry, had a sub-cluster of: Bedside specialty with family orientation affording long-term patient care. Another sub-cluster was time for childrearing and family, only daytime work and outpatient care. Clusters also revealed students' perceptions that differed from expected: Cardiology is changing from a cognitive to a procedure-oriented subspecialty, clustering not only with internal medicine and its subspecialties but also with emergency medicine, surgical subspecialties and anesthesiology. CONCLUSIONS: The concept that career choice involves selecting from a cluster of related specialties provides information about the specialties students might be considering. Moreover, students are not only looking for individual aspects of a specialty, but for a package including clusters of socio-economic and occupational features. Practically, examining clusters can help in career counseling of medical students and assist residency program directors in marketing their specialties.

Undergraduate medical education in general practice/family medicine throughout Europe - a descriptive study.

BACKGROUND: It is increasingly becoming evident that a strong primary health care system is more likely to provide better population health, more equity in health throughout the population, and better use of economic resources, compared to systems that are oriented towards specialty care. Developing and maintaining a strong and sustainable primary health care requires that a substantial part of graduating doctors go into primary care. This in turn requires that general practice/family medicine (GP/FM) strongly influences the curricula in medical schools. In the present paper we aim at describing the extent of GP/FM teaching in medical schools throughout Europe, checking for the presence of GP/FM curricula and clinical teaching in GP offices. METHODS: A brief questionnaire was e-mailed to GP/FM or other professors at European medical universities. RESULTS: 259 out of 400 existing universities in 39 European countries responded to our questionnaire. Out of these, 35 (13.5%) reported to have no GP/FM curriculum. These 35 medical faculties were located in 12 different European countries. In addition, 15 of the medical schools where a GP/FM curriculum did exist, reported that this curriculum did not include any clinical component (n = 5), or that the clinical part of the course was very brief - less than one week, mostly only a few hours (n = 10). In total, 50 universities (19%) thus had no or a very brief GP/FM curriculum. These were mainly located in the Eastern or Southern European regions. CONCLUSION: It is still possible to graduate from European medical universities without having been exposed to a GP/FM curriculum. The European Academy of Teachers in General Practice (EURACT) will launch efforts to change this situation.

A retrospective analysis of the sentence writing component of the Mini Mental State Examination: cognitive and affective aspects.

BACKGROUND: One of the components of the Mini Mental State Examination (MMSE) is the request to write a sentence. We investigated the relationship between the characteristics of the written sentence of the MMSE and the cognitive and affective status of elderly patients. METHODS: The characteristics of the sentence were compared to the total MMSE score, sociodemographic characteristics, tests evaluating cognition and affective status, and diagnoses. RESULTS: The number of words was significantly associated with the degree of cognitive impairment, whereas the emotional polarity of sentences and concerns about health were associated with depression. CONCLUSIONS: Characteristics of the MMSE sentence may provide important additional information regarding both cognition and affect when assessing older people.

Using marketing research concepts to investigate specialty selection by medical students.

OBJECTIVES: This study was intended to examine whether a marketing research approach improves understanding of medical specialty selection by medical students. This approach likens students to consumers who are deciding whether or not to purchase a product (specialty). This approach proposes that when consumers' criteria match their perceptions of a product's features, the likelihood that they will purchase it (select the specialty) increases. This study examines whether exploring students' selection criteria and perceptions of various specialties provides additional insights into the selection process. METHODS: Using a consumer behaviour model as a framework, a questionnaire was designed and administered to Year 6 (final-year) students in 2008 and 2009 to elicit information on their knowledge about and interests in various specialties, the criteria they used in specialty selection, and their perceptions of six specialties. RESULTS: A total of 132 (67%) questionnaires were returned. In many instances, consistency between selection criteria and perceptions of a specialty was accompanied by interest in pursuing the specialty. Exceptions were noted and pointed to areas requiring additional research. For example, although > 70% of female students replied that the affordance of a controllable lifestyle was an important selection criterion, many were interested in obstetrics and gynaecology despite the fact that it was not perceived as providing a controllable lifestyle. Minimal overlap among students reporting interest in primary specialties that possess similar characteristics (e.g. paediatrics and family medicine) demonstrated the need to target marketing (recruitment) efforts for each specialty individually. CONCLUSIONS: Using marketing research concepts to examine medical specialty selection may precipitate a conceptual shift among health care leaders which acknowledges that, to attract students, specialties must meet students' selection criteria. Moreover, if consumers (students) deem a product (specialty) unattractive, it may need to be examined further to improve its appeal.

Adverse pregnancy outcomes including gestational diabetes and preeclampsia: Do primary care physicians refer to them in their medical files?

Aims: Pregnancies complicated with gestational diabetes mellitus (GDM) or preeclampsia should be considered risk factors for subsequent morbidity later in a women's life. Appropriate screening tests have been recommended for these women. We sought to evaluate whether primary care physicians document diagnoses of GDM or preeclampsia in the medical files during the post-partum period and to elicit whether appropriate screening tests were performed.Materials and methods: The medical records of 352 women discharged from the maternity ward with a diagnosis of GDM or preeclampsia were examined 12 weeks post-partum. We recorded whether a primary care visit occurred, if a relevant diagnosis was documented and if screening tests were conducted.Results: In our cohort, 89.2% of the GDM group and 81.0% of the preeclampsia group visited a primary care physician at least once. About 12.9% (n = 25) of the GDM group and 12.7% (n = 20) of the preeclampsia group were given a correct diagnosis; 40.7% of the GDM group underwent a diabetes screening test and 27.8% of the preeclampsia group underwent a blood pressure measurement.Conclusion: We concluded that diagnoses of GDM and pre-eclampsia are not well-documented by primary physicians and that recommended screening tests are not being sufficiently performed.

Serum 25-OH vitamin D levels in patients with fibromyalgia.

BACKGROUND: The association between low levels of 25-hydroxyvitamin D and non-specific musculoskeletal pain, including fibromyalgia syndrome, is controversial. Several studies have reported a "positive association" and two others found "no association." OBJECTIVES: To test levels of 25OHD in patients with fibromyalgia syndrome and in matched controls. METHODS: The study population comprised 68 premenopausal women with a diagnosis offibromyalgia and 82 age-matched premenopausal women without. The former were identified from the computerized medical databases of five primary care urban clinics in the south of Israel, and the control subjects were attending the participating clinics for regular periodic blood tests. For each patient, the matched control interview and blood test were performed within a week or two from the patient's interview and blood test, thus controlling for expected seasonal variations. RESULTS: Serum 25OHD was measured using different cutoff levels and compared between the groups (< 30 ng/ml, < 20 ng/ml and <15 ng/ml). No statistically significant differences were found between the groups regardless of the cutoff level used. A logistic regression model for predicting women with 25OHD levels 20 ng/ml showed that all the variables examined in both groups (age, country of birth, education) were not statistically significant. We found the expected seasonal variations of 25OHD levels, though these were not statistically significant. CONCLUSIONS: We found no association between fibromyalgia and low 25OHD levels as previously suggested in other studies.

Improving combined diabetes outcomes by adding a simple patient intervention to physician feedback: a cluster randomized trial.

BACKGROUND: Research on synergistic effects of patient targeted interventions combined with physician-targeted interventions has been limited. OBJECTIVES: To compare a combined physician-patient intervention to physician feedback alone on a composite outcome of glycemic, lipid and blood pressure control. METHODS: In this cluster study 417 patients with adult-type 2 diabetes from four primary care clinics were randomized to receive either a physician-only intervention or a combined physician-plus-patient intervention. Physicians in all clinics received diabetes-related quality performance feedback during staff meetings. Patients at combined-intervention clinics also received a letter encouraging them to remind their doctors to address essential aspects of diabetes care at the next visit. At 1 year follow-up, outcome measurements included hemoglobin A1c, low density lipoprotein-cholesterol and systolic blood pressure: namely, the proportion of patients with HbA1c 9%, LDL <130 mg/dl and SBP <140 mmHg both as separate outcomes and combined. RESULTS: After adjusting for patient characteristics and baseline measures, follow-up levels of HbA1c (7.5% vs. 7.8%, P = 0.09), LDL (104.7 vs. 110.7 mg/dl, P < 0.05) and SBP (135.6 vs. 139.9, P = 0.10) were marginally better for combined-intervention patients compared to physician-only intervention patients. Significantly more patients in the combined-intervention (38.8%) than physician-only intervention (24.2%) met all three targets (HbA1c (9%, LDL (130 mg/dl and SBP <140 mmHg) as a single combined outcome (adjusted odds ratio 2.4, P < .01). CONCLUSIONS: Compared to physician-feedback alone, a dual intervention combining a patient letter with physician feedback produced modest improvements in glycemic, lipid and blood pressure control individually, but substantial improvement in a combined measure of these three outcomes together. Using composite outcomes may detect meaningful improvements in the management of complex chronic disease.

Medical specialty selection criteria of Israeli medical students early in their clinical experience: subgroups.

BACKGROUND: Israeli medical school classes include a number of student subgroups. Therefore, interventions aimed at recruiting medical students to the various specialties should to be tailored to each subgroup. METHODS: Questionnaires, distributed to 6 consecutive 5th-year classes of the Hebrew University - Hadassah School of Medicine, elicited information on criteria for choosing a career specialty, criteria for choosing a residency program and the importance of finding a specialty interesting and challenging when choosing a residency. RESULTS: Completed questionnaires were returned by 540 of 769 (70%) students. The decision processes for choosing a medical specialty and choosing a residency program were different. Family and colleagues had minimal influence on choosing a specialty, while family and their residential locality had much influence on choosing a residency, especially among women. Older age, marriage, and spousal influence were positively associated with choice of a specialty. Two-thirds of the students had completed military service, 20% were attending medical school prior to military service, 5% had completed national service and 9% had entered medical school without serving. Despite the pre-military subgroup being younger and having another 7 years of medical school, internship and military service before residency, they had begun thinking about which specialty to choose, just like the post-military students. When choosing a residency program, post-military women were more influenced by their families and family residential locality than their pre-military counterparts; differences ascribed to the older and often married post-military women having or wanting to begin families. This difference was reinforced by fewer post- than pre-military women willing to wait 2-3 years for a residency in the specialty that interested them most and were willing to begin residency immediately after internship in a specialty that interested them less. CONCLUSIONS: Medical school classes are composed of various subgroups, each with its own characteristics. It is important to differentiate between choosing a specialty and a residency program. Choosing a specialty is a uniquely personal decision with some spousal influence among married students. It is of central importance even among pre-military students not slated to begin residency for many years. In contrast, choosing a residency program is influenced by family, where one grew up and other family-related considerations.

Challenges to the Israeli healthcare system: attracting medical students to primary care and to the periphery.

BACKGROUND: The greatest challenges facing healthcare systems include ensuring a sufficient supply of primary care physicians and physicians willing to work in rural or peripheral areas. Especially challenging is enticing young physicians to practice primary care in rural/peripheral areas. Identifying medical students interested in primary care and in residencies in Israel's periphery should aid the healthcare leadership. It may be particularly important to do so during the clinical years, as this is the stage at which many future physicians begin to crystallize their specialty and location preferences. METHODS: Questionnaires, distributed to 6 consecutive 5th-year classes of the Hebrew University - Hadassah School of Medicine, from 2010 to 2016, elicited information on criteria for choosing a career specialty, criteria for choosing a residency program and whether one-time monetary grants authorized in the 2011 physicians' union contract would attract students to residencies in the periphery. RESULTS: Completed questionnaires were returned by 511 of 740 (69%) students. Ninety-eight (19%) were interested in a primary care residency, 184 (36%) were unsure and 229 (45%) were not interested. Students interested in primary care were significantly less interested in specialties that perform procedures/surgeries and in joining a medical school faculty, while being more inclined towards specialties dealing with social problems, controllable lifestyles and working limited hours. The percentage of students interested in primary care was stable during the study period. Forty-eight of the students indicated interest in residencies in the country's periphery, and 42% of them were also interested in primary care residencies. Overall, only 3.7% of students were interested in both a primary care residency and a residency in the periphery. Thirty percent of the students indicated that the monetary incentives tempted them to consider a residency in the periphery. Fifty-three percent of these students reported that they did not yet know the geographic area where they wished to do their residency, as compared to only 22% among those not interested in incentives. CONCLUSIONS: This study provides the healthcare leadership with information on the characteristics of the students at a centrally-located medical school who tend to be more interested in primary care and in working in the periphery. Specifically, the study found that students interested in primary care desire a positive life/work balance, something that Israeli non-hospital primary care practice provides. Students considering residencies in the periphery were similarly inclined. Moreover, about a third of students had positive thoughts about monetary incentives for residencies in peripheral hospitals. These students should be identified early during their clinical experience so that attempts to recruit them to the periphery can commence before their specialty and location preferences have fully crystallized. Parallel studies should be performed at additional Israeli medical schools.

Medical students' perceptions of a career in family medicine.

BACKGROUND: In Israel, there is a shortage of family medicine (FM) specialists that is occasioned by a shortage of students pursuing a FM career. METHODS: A questionnaire, based on methods adapted from marketing research, was used to provide insight into the medical specialty selection process. It was distributed to 6th-year medical students from two Israeli medical schools. RESULTS: A response rate of 66% resulted in collecting 218 completed questionnaires. Nineteen of the students reported that they were interested in FM, 68% of them were women. When compared to students not interested in FM, the selection criteria of students interested in FM reflected greater interest in a bedside specialty which provides direct long-term patient care. These latter students were also more interested in a controllable lifestyle that allowed time to be with family and children and working outside the hospital especially during the daytime. These selection criteria aligned with their perceptions of FM, which they perceived as providing them with a controllable lifestyle, allowing them to work limited hours with time for family and having a reasonable income to lifestyle ratio. The students not interested in FM, agreed with those interested in FM, that the specialty affords a controllable lifestyle and the ability to work limited hours Yet, students not interested in FM more often perceived FM as being a boring specialty and less often perceived it as providing a reasonable income to lifestyle ratio. Additionally, students not interested in FM rated the selection criteria, academic opportunities and a prestigious specialty, more highly than did students interested in FM. However, they perceived FM as neither being prestigious nor as affording academic opportunities CONCLUSION: This study enriches our understanding of the younger generation's attitudes towards FM and thus provides administrators, department chairs and residency program directors with objective information regarding selection criteria and the students' perceptions of FM. We identified the disconnect between the selection criteria profiles and the perceptions of FM of students not inclined to pursue a residency in FM. This allowed for recommendations on how to possibly make FM more attractive to some of these students.

Ethnic differences in preventive medicine: the example of Jewish Ethiopian women in Israel.

BACKGROUND: Studies have found ethno-cultural disparities in health care delivery in different countries. Minority populations may receive lower standards of care. OBJECTIVES: To test a hypothesis that Jewish Ethiopian women may be receiving fewer preventive recommendations than other women in Israel. METHODS: A telephone survey was conducted using a structured questionnaire designed specifically for this study in Hebrew, Russian and Amharic (Semitic language of Ethiopia). The study group included 51 post-menopausal women of Ethiopian origin, aged 50-75. The control group included 226 non-Ethiopians matched for age, some of whom were immigrants from the former Soviet Union. The questionnaire dealt with osteoporosis and breast cancer screening and prevention. RESULTS: All the parameters measured showed that the general population received more preventive recommendations and treatment than did Jewish Ethiopian women, including manual breast examination, mammography, osteoporosis prevention, bone density scans, and recommendations for a calcium-rich diet, calcium supplementation, hormone replacement therapy, biphosphonates and raloxifen. On a logistic regression model the level of knowledge of the Hebrew language, age, ethnicity and not visiting the gynecologist were significantly related to not having received any preventive medicine recommendations. CONCLUSIONS: Differences in cultural backgrounds and language between physicians and their patients may obstruct the performance of screening and preventive medicine. Recognizing this potential for inequity and using methods to overcome these barriers may prevent it in the future.

Hypothesis: A single dose of an anxiolitic may prevent unnecessary visits to the emergency room during blood pressure elevations.

Blood pressure (BP) monitoring devices are very commonly used by the general public for self-measurement. Approximately 19% of people using these devises check their BP every day or almost every day and only one third use them because their doctor recommended it. Measurement often causes anxiety and anxiety increases blood pressure in the short term. Elderly patients often visit the emergency room (ER) due to these BP elevations. Almost 10% of patients presenting to ERs complained of high BP, and between 50-75% of them receive antihypertensive drugs (sometimes with serious adverse effects) despite the fact that only 7.5% are classified as hypertensive emergencies, and only 2.8% are at risk of serious outcome. Two studies suggested the use of anxiolitics in the treatment of excessive hypertension. When compared to captopril, treatment with diazepam or alprazolam showed to be effective in lowering BP, with no significant difference between the two groups. We therefore suggest that patients with acute elevations of BP (measured at home) try an anxiolytic before deciding to go to the ER. Patients in which BP lowers with the use of tranquilizers do not need to go to the ER. We also suggest using this strategy in patients visiting community clinics and ER for the same reason. Our hypothesis is that by using our suggestions there will be a significant reduction in the number of unnecessary visits to the ER, the use of medication that may produce serious adverse effects, and an important health cost reduction, without increasing the risk for patients (a 10% reduction of ER visits may save up to 300 million dollars/year in the US alone and prevent unnecessary use of medical facilities and manpower).

Neutropenia and eosinophilia among Ethiopian immigrants to Israel: Familial or environmental?

BACKGROUND: Due to trends of population movements, Israeli family physicians are treating increasing numbers of African immigrants from Ethiopia. These immigrants were found to have complete blood counts (CBC) that are different from other ethnic groups, with a higher prevalence of eosinophilia and neutropenia. OBJECTIVES: To evaluate haematological findings in an attempt to define whether they behave as familial (genetic) or environmental. METHODS: Retrospective chart review of 300 patients from a primary care clinic: 100 individuals of Ethiopian heritage born in Ethiopia (EE); 100 individuals of Ethiopian heritage born in Israel, whose parents were born in Ethiopia (EI), and a control group of 100 patients who were not of Ethiopian heritage (C). RESULTS: Absolute eosinophilia (greater than 500/dl) was found in 13% of the EE study group significantly higher than the two other groups (P < 0.05), with no difference between EI and C. neutropenia (defined as less than 1500/dl) was found in 32% of EE group, 20% of EI, and 1% of C (P < 0.01). CONCLUSION: On the one hand, findings point to a marked environmental influence on the eosinophilic response (most probably due to intestinal parasites present in immigrants from Ethiopia). On the other hand, a familial-genetic nature is probably the reason for the higher prevalence of neutropenia in this population, although some environmental influence may play a role. The knowledge of these findings may be useful for physicians treating people migrating from Africa.

[The creation of a national faculty development program in Israel for family physicians].

University Departments from many countries recruit their faculty members for academic duties without prior formal training (specific for their jobs). This has been the common approach in Israel. Other countries however, have created faculty development (FD) programs to help new faculty accomplish their new tasks. This article describes the creation of the first National Faculty Development Program in Israel for Family Physicians. The main goals of a comprehensive FD program are to improve vitality in education, promote academic excellence and develop professional and organizational leadership. In 1998, the Israeli Society of Teachers in Family Medicine decided to develop a National Program to deal with basic FD requirements. Family Physicians and educationalists worked together at its development and cooperated in co-teaching. The program was launched in 2001 and we are now in the process of evaluating the first year and the development of the second course. We chose a format similar to the program from the University of Toronto. Twenty-three family physicians enrolled in the course. Half of the participants were born and trained in medicine in Israel. After completing the first year of this program, both participants and teachers provided positive feedback and requests were received for a second course for new participants.