Power Gaps Among Stakeholders in Israel's Primary Care and the Role of Primary Care Physicians' Relative Power in Their Intention to Use Video-Consultations with Patients.

Introduction: Although some correlates of primary care physicians (PCPs) telemedicine adoption have been studied, little is known about whether the intention to use video-consultations (VCs) relates to how PCPs view their power, relative to other stakeholder groups in primary care. The aim of this study was (1) to describe PCPs', patients', and policy makers' (PMs) views of their power and (2) to explore how PCPs views of power are associated with their intention to use VC. Methods: A convergent parallel mixed-methods design was used. Interviews were conducted with five focus groups that comprised 42 patients; five focus groups with 52 PCPs; and 24 individual interviews with PMs. A total of 508 patients, 311 PCPs, and 141 PMs completed the questionnaire, assessing intention to use VC and stakeholders' relative power. The qualitative data were analyzed using the thematic method; survey data were analyzed using quantitative methods. Results: All stakeholder groups rated PCPs' power as significantly lower, relative to that of patients and managers. PCPs' intention to use telemedicine was found to be significantly related to perceived power gaps between them and patients (r = -0.24, p < 0.001) and between them and managers (r = -0.45, p < 0.001). Themes revealed in the analysis describing how PCPs' low power influences their intention to use VC were as follows: PCPs' low-impact telemedicine-related decisions, increased work overload, "big brother" control, and Health Maintenance Organization demands for telemedicine mandatory usage. Conclusions: To successfully adopt VC, efforts should be made to increase PCPs' relative power, by strengthening their involvement in decision-making procedures and by increasing PCPs' control over their work environment.

Choosing Video Instead of In-Clinic Consultations in Primary Care in Israel: Discrete Choice Experiment Among Key Stakeholders-Patients, Primary Care Physicians, and Policy Makers.

BACKGROUND: Despite its innovative benefits, the adoption of video consultations (VCs) in primary care settings is complex and slow. OBJECTIVES: To quantify the preferences of key stakeholders in Israel's primary care-patients, primary care practitioners, and policy makers-regarding VCs compared with traditional in-clinic consultations (ICC) in nonurgent conditions. METHODS: Discrete choice experiment surveys were completed by 508 patients, 311 physicians, and 141 policy makers. These consisted of 12 choice tasks of 2 labeled alternatives (VC or ICC), with the 4 attributes most relevant to each stakeholder group. A random effects logit model analysis was used to estimate stakeholders' preferences. RESULTS: All 4 experiments' attributes were significantly important in choosing VC versus ICC for the patient group and the physician group. Three out of 4 attributes were significantly important to policy makers. Differences and similarities between stakeholders were identified in attribute rank order, trade-offs, and VC uptake probabilities. Policy makers' VC uptake rate was 86%. Patients' preferences suggested that 68% of ICCs could be replaced by VCs. Physicians' VC uptake was 30% in cases in which the consultation purpose was to diagnose and provide treatment and 48% in cases in which the consultation purpose was follow-up. CONCLUSIONS: Our findings show key stakeholders' preferences about VC integration, to be considered when these systems are introduced into primary care and optimize the implementation process. Although there is a stronger preference for ICC among physicians and patients, alternative combinations of attribute levels might be used to compensate and reconfigure a more preferred VC service.

The association between patients' perceived continuity of care and beliefs about oral anticancer treatment.

PURPOSE: To explore factors associated with necessity beliefs and concerns among patients receiving oral anticancer therapy (OACT) and, specifically, to examine the relationship between continuity of care (COC) and patients' beliefs about OACT. METHODS: A cross-sectional study was conducted among patients from four oncology centers receiving OACT (either targeted, hormonal, or chemotherapy). Two months after OACT initiation, patients were asked to participate in a face-to-face or telephone survey. The Beliefs about Medicines Questionnaire was used to examine patients' perceptions of their personal necessity for OACT and concerns about potential adverse effects. The Nijmegen Continuity Questionnaire was used to assess patients' perceived COC. Data on clinical characteristics were collected from medical records. RESULTS: Participants' beliefs about OACT necessity (n = 91) were found to be associated with COC within the oncology team, and with COC between the oncology specialist and the primary care physicians (ß = 0.27, p = 0.003; ß = 0.22, p = 0.02, respectively), beyond age, depression, and cancer type (ΔR2 = 0.14, p < 0.001). Additionally, the difference between participants' beliefs about OACT necessity and their OACT-related concerns was associated with COC within the oncology team (ß = 0.30, p = 0.001), beyond age, income, family status, and cancer type (ΔR2 = 0.09, p = 0.001). CONCLUSIONS: This study shows that cancer patients' perceptions about the COC between care providers are related to their beliefs about OACT necessity, thus providing evidence for the importance of health care delivery approaches that support COC within the oncology team and between the oncology specialist and the primary care physician.

Correction to: A Life Course Perspective on the Ways Older Men and Women Discuss Sexual Issues.

The surname of co-author Inbar Levkovich was misspelled (as "Levkovitz") in this originally published article. The original article has been corrected. The corresponding author apologizes for not detecting this error during the proof correction phase.

A Life Course Perspective on the Ways Older Men and Women Discuss Sexual Issues.

The present study examined how older adults communicate about sexual issues in light of the tremendous societal changes that have taken place with regard to sexuality in the past few decades. We relied on interviews with 47 Israelis 60 years of age and older who were instructed to discuss sexuality in old age and its unique characteristics, using semi-structured interviews. Analysis consisted of repeated comparisons and contrasts to identify common themes. A common thread of "secrets and lies" characterized the discussion of sexual issues throughout the life course of respondents. The findings showed that although older adults have been aware of the limited information provided to them during their upbringing and of the limited room allowed to sexuality in their emerging adulthood years, many have continued to find it difficult to address sexual issues, even in later life. Moreover, many perceived the information currently available about sexuality and the contemporary approach to sexuality brought by the media or their children and grandchildren as being somewhat inadequate. Implications for practice are discussed.

The Experience of Fatigue in Breast Cancer Patients 1-12 Month Post-Chemotherapy: A Qualitative Study.

The study explored the experience of fatigue, its effects and ways of coping with fatigue and the role of family and social support among breast cancer patients. In-depth, semi-structured interviews were conducted with 13 breast cancer patients stages I-III, aged 34-67, who were up to one year after the termination of chemotherapy. Two main themes emerged: "Being imprisoned in the body of an 80-year-old," focuses the fatigue experienced by younger and older women, during and post treatment, including the different patterns of fatigue and the various means of coping with fatigue; The "Family's bear-hug" exemplifies the role of the environment in coping with the experience of fatigue and the complexities entailed in receiving support from family and friends. The study provides a comprehensive picture of fatigue in its various contexts during and post-treatment and its impact on family relations and quality of life among younger and older breast cancer patients.

Engaging family medicine residents in research training: An innovative research skills program in Israel.

Background: The importance of medical research in developing academic and clinical excellence is widely acknowledged. Obstacles hindering research in primary care include negative attitudes, lack of dedicated time, funding shortages, and a relative paucity of mentors. Residency is the appropriate stage for developing research skills and encouraging research performance. In this article, we describe an intensive research training program offered at the family medicine (FM) Department, Technion Faculty of Medicine in Haifa, Israel. The program aims to engage residents in FM in constructing a research protocol to provide them with a positive experience, help them to overcome barriers, and enhance their research performance. Methods: Learning is achieved through a course design that includes the following six components: (1) course website: a platform for online collaborative learning; (2) inverted classroom: theory is learned through website video lectures and presentations during resident's own time according to a guided schedule, while weekly classroom sessions are dedicated to step-by-step implementation of theory, group discussion, and individual mentoring; (3) Peer feedback; (4) personal mentoring; (5) presentation of the protocol to peers and senior department staff at the end of the course; and (6) evaluation of protocol presentation and engagement during the research course as well as possibilities for further development. Results: Five teams of residents went on to conduct full research projects. Their studies have been presented at seven national and three international conferences, and one has been published. The outcomes of these studies have been useful in FM practices and have inspired residents to continue scholarly work in our department. Discussion: Innovation in teaching methods enhances engagement in learning research skills among residents and may encourage them to conduct research in primary care.

Views of family physicians on heterosexual sexual function in older adults.

BACKGROUND: Sexual functioning among older adults has received little attention in research and clinical practice, although it is an integral part of old age. As older adults tend to consume health services and to visit family physicians more frequently, these care-providers serve as gatekeepers in the case of sexual concerns. The present study evaluated the perceptions of family physicians regarding sexuality in older adults. METHOD: Qualitative interviews with 16 family physicians were conducted. We used in-depth, semi-structured interviews. RESULTS: Three main themes emerged: 1. Family physicians described having difficulty in raising questions about sexuality to older patients. 2. Family physicians tended towards the biological side of the spectrum, focusing on the patient's medical problem and asking physiological questions. 3. Family physicians mainly related to medication administered to their male patients, whereas a minority also described the guidance they provided to older individuals and couples. CONCLUSIONS: The study shows that family physicians tend not to initiate discourse with older patients on sexuality, but rather discuss sexuality mostly in conjunction with other medical conditions. Implications for research and practice are discussed.

Barriers to the Treatment of Mental Illness in Primary Care Clinics in Israel.

The present study examined physicians' perceived barriers to the management of mental illness in primary care settings in Israel. Seven focus groups that included a total of 52 primary care Israeli physicians were conducted. Open coding analysis was employed, consisting of constant comparisons within and across interviews. Three major themes emerged: (a) barriers to the management of mental illness at the individual-level, (b) barriers to the management of mental illness at the system-level, and (c) the emotional ramifications that these barriers have on physicians. The findings highlight the parallelism between the experiences of primary care physicians and their patients. The findings also stress the need to attend to physicians' emotional reactions when working with patients who suffer from mental illness and to better structure mental health treatment in primary care.

Managing Diabetes Mellitus: A Survey of Attitudes and Practices Among Family Physicians.

Due to the increasing prevalence of diabetes and the shortage of endocrinologists, family physicians have an important role in diabetes management. The purpose of this study was to examine the sources of knowledge, attitudes and practices of family physicians regarding the management of type 2 diabetes. Attendees at continuous medical education (CME) programs in Israel were requested to respond anonymously to written questions about their sources of knowledge about diabetes, the methods of diabetes management they advise their patients, their knowledge of diabetes medication treatments, and their attitudes toward people with type 2 diabetes. Questionnaires were completed by 362 family physicians (79% response rate). Of them, 329 (91%) reported that they usually manage their patients' diabetes care, including that of patients with concomitant risk factors. Their most common recommendations for diabetes control were: to increase physical activity, decrease total calorie intake, consult with a dietitian and undergo weight loss counseling. Almost all physicians (97%) reported providing lifestyle change counseling. Sixty percent reported lacking knowledge about nutritional issues. Only 58% answered correctly regarding the effect of the anti-diabetic drug, GLP1 analog. Board certified family physicians and their residents exhibited more knowledge about diabetes practice than did non-board certified family physicians. The great majority of family physicians surveyed usually manage their patients' diabetes themselves, and do not refer them to diabetes specialists. The implementation of strategies that will enhance the competencies and confidence of family physicians in diabetes management are important for achieving successful treatment.

Association of Vitamin B12 Deficiency with Homozygosity of the TT MTHFR C677T Genotype, Hyperhomocysteinemia, and Endothelial Cell Dysfunction.

BACKGROUND: Hyperhomocysteinemia is associated with increased cardiovascular risk, but treatment with folic acid has no effect on outcome in unselected patient populations. OBJECTIVES: To confirm previous observations on the association of homozygosity for the TT MTHFR genotype with B12 deficiency and endothelial dysfunction, and to investigate whether patients with B12 deficiency should be tested for 677MTHFR genotype. METHODS: We enrolled 100 individuals with B12 deficiency, tested them for the MTHFR C677T polymorphism and measured their homocysteine levels. Forearm endothelial function was checked in 23 B12-deficient individuals (13 with TT MTHFR genotype and 10 with CT or CC genotypes). Flow-mediated dilatation (FMD) was tested after short-term treatment with B12 and folic acid in 12 TT MTHFR homozygotes. RESULTS: Frequency of the TT MTHFR genotype was 28/100 (28%), compared with 47/313 (15%) in a previously published cohort of individuals with normal B12 levels (P = 0.005). Mean homocysteine level was 21.2 ± 16 µM among TT homozygotes as compared to 12.3 ± 5.6 µM in individuals with the CC or CT genotype (P = 0.008). FMD was abnormal ( 6%) in 9/13 TT individuals with B12 deficiency (69%), and was still abnormal in 7/12 of those tested 6 weeks after B12 and folic treatment (58%). CONCLUSIONS: Among individuals with B12 deficiency, the frequency of the TT MTHFR genotype was particularly high. The TT polymorphism was associated with endothelial dysfunction even after 6 weeks of treatment with B12 and folic acid. Based on our findings we suggest that B12 deficiency be tested for MTHFR polymorphism in order to identify potential vascular abnormalities and increased cardiovascular risk.

[Modeling integrative oncology care program for Arab patients in north Israel: towards quality of life improvement during chemotherapy].

BACKGROUND: In the last decade, a number of integrative oncology programs have been established within leading oncology departments in Israel aiming to provide consultations that address patients' concerns and improve their quality of life (QOL). OBJECTIVE: To identify Arab cancer patients' attitudes, needs and expectations concerning integration of complementary and traditional medicine (CTM) in their supportive oncology care. METHODS: This article presents studies based on both qualitative (including interviews with patients, oncologists and CTM practitioners) and quantitative studies which were designed to evaluate patients' attitudes, needs and expectations regarding CTM integration in supportive oncology care. RESULTS: Of the 313 Arab respondents, 109 reported on the use of herbal medicine for cancer-associated outcomes. Over 78% of respondents considered QOL improvement as their main expectation of integrated CM consultation. Similar expectations were expressed in studies exploring 155 cancer care practitioners in Israel and Arab countries, 27 CTM-trained Arab practitioners, and a sample of 15 Arab patients referred to integrative medicine consultation. CONCLUSIONS: Arab cancer patients support QOL-oriented integrated medicine programs provided in oncology settings. Integrative medicine consultation should provide patients with an evidence-based recommendation on efficacy and safety of herbs commonly used concomitant with chemotherapy. We recommend designing integrative oncology training courses for physicians who will provide evidence-based consultation attuned with Arab patients' needs, concerns and cultural-sensitive orientation.

Factors associated with adherence to glaucoma pharmacotherapy in the primary care setting.

BACKGROUND: Primary open-angle glaucoma is a leading cause of irreversible blindness. OBJECTIVES: To identify factors associated with adherence to glaucoma pharmacotherapy in the primary care setting, focusing on physicians' role. METHODS: Patients were recruited from primary care clinics and telephone-interviewed using a structured questionnaire that addressed patient-, medication-, environment- and physicians-related factors. Patients' data on pharmacy claims were retrieved to calculate the medication possession ratio for measuring adherence. RESULTS: Seven hundred thirty-eight glaucoma patients were interviewed. The multivariate analysis identified eight variables that were associated independently with adherence. Barriers to adherence were found to be low income, believing that 'It makes no difference to my vision whether I take the drops or not' and relying on someone else for drop instillation (exp(B) = 1.91, P = 0.002; exp(B) = 2.61, P < 0.0001; exp(B) = 2.17, P = 0.001, respectively). Older age, having a glaucoma patient among close acquaintances, taking a higher number of drops per day, taking a prostaglandin drug and reporting that the ophthalmologist had discussed the importance of taking eye drops as prescribed, were found to promote adherence (exp(B) = 0.96, P < 0.0001; exp(B) = 0.54, P = 0.014; exp(B) = 0.81, P = 0.001; exp(B) = 0.37, P < 0.0001; exp(B) = 0.60, P = 0.034, respectively). No association was found between the patient's relationship with the family physician and adherence to glaucoma treatment. CONCLUSION: Adherence to glaucoma pharmacotherapy is associated with patient-related, medication-related, physician-related and environmental factors. Ophthalmologists have a significant role in promoting adherence. However, the potential role of family physicians is unfulfilled and unrecognized.

The use of abstract paintings and narratives to foster reflective capacity in medical educators: a multinational faculty development workshop.

Reflective capacity is integral to core healthcare professional practice competencies. Reflection plays a central role in teacher education as reflecting on teaching behaviours with critical analysis can potentially improve teaching practice. The humanities including narrative and the visual arts can serve as a valuable tool for fostering reflection. We conducted a multinational faculty development workshop aiming to enhance reflective capacity in medical educators by using a combination of abstract paintings and narratives. Twenty-three family physicians or physicians-in-training from 10 countries participated in the workshop. Qualitative assessment of the workshop showed that the combined use of art and narrative was well received and perceived as contributing to the reflective exercise. Participants generally felt that viewing abstract paintings had facilitated a valuable mood transformation and prepared them emotionally for the reflective writing. Our analysis found that the following themes emerged from participants' responses: (1) narratives from different countries are similar; (2) the use of art helped access feelings; (3) viewing abstract paintings facilitated next steps; (4) writing reflective narratives promoted examination of educational challenges, compassion for self and other, and building an action plan; and (5) sharing of narrative was helpful for fostering active listening and appreciating multiple perspectives. Future research might include comparing outcomes for a group participating in arts-narrative-based workshops with those of a control group using only reflective narrative or in combination with figurative art, and implementing a combination of qualitative and quantitative methods of assessment.

Barriers to integration of traditional and complementary medicine in supportive cancer care of arab patients in northern Israel.

In 2008, an Integrative Oncology Program (IOP), aiming to improve patients' quality of life during chemotherapy and advanced cancer, was launched within the Clalit Health Organization's oncology service at the Lin Medical Center, Haifa, Israel. The IOP clinical activity is documented using a research-based registry protocol. In this study, we present an analysis of the registry protocol of 15 Arab patients with cancer who were referred to the IOP. Analysis of patients' reported outcomes using the Edmonton Symptom Assessment Scale suggests that integrative medicine care improves fatigue (P = 0.024), nausea (P = 0.043), depression (P = 0.012), anxiety (P = 0.044), appetite (P = 0.012), and general well-being (P = 0.031). Barriers to integration of traditional and complementary medicine in supportive care of Arab patients are discussed followed by six practical recommendations aimed at improving accessibility of patients to integrative supportive care, as well as compliance with treatments.

High prevalence of childhood asthma in Northern Israel is linked to air pollution by particulate matter: evidence from GIS analysis and Bayesian Model Averaging.

The medical records of 3922 school children residing in the Greater Haifa Metropolitan Area in Northern Israel were analyzed. Individual exposure to ambient air pollution (SO(2) and PM(10)) for each child was estimated using Geographic Information Systems tools. Factors affecting childhood asthma risk were then investigated using logistic regression and the more recently developed Bayesian Model Averaging (BMA) tools. The analysis reveals that childhood asthma in the study area appears to be significantly associated with particulate matter of less than 10 µm in aerodynamic diameter (PM(10)) (Odds Ratio (OR) = .11; P<0.001). However, no significant association with asthma prevalence was found for SO(2) (P >0.2), when PM(10) and SO(2) were introduced into the models simultaneously. When considering a change in PM(10) between the least and the most polluted parts of the study area (9.4 µg/m(3)), the corresponding OR, calculated using the BMA analysis, is 2.58 (with 95% posterior probability limits of OR ranging from 1.52 to 4.41), controlled for gender, age, proximity to main roads, the town of a child's residence, and family's socio-economic status. Thus, it is concluded that exposure to airborne particular matter, even at relatively low concentrations (40-50 µg/m(3)), generally below international air pollution standards (55-70 µg/m(3)), appears to be a considerable risk factor for childhood asthma in urban areas. This should be a cause of concern for public health authorities and environmental decision-makers.

Exploring association of spiritual perspectives with complementary medicine use among patients with Type 2 diabetes in Israel.

BACKGROUND: Spirituality, as distinct from religiosity, has become a most common term in complementary and alternative medicine (CAM) discourse. The association between religiosity and spirituality in the context of CAM use is a complex one and is worthy of being researched in specific local cultural contexts. OBJECTIVE: Exploring the association between CAM use and religiosity, in patients with and without diabetes Type 2 attending primary care clinics in Northern Israel. RESEARCH DESIGN AND METHODS: Research assistants administered a questionnaire developed to assess CAM use in primary care to a convenience sample of patients attending seven primary care clinics. RESULTS: Of the 3742 respondents, 485 (12.9%) reported having Type 2 diabetes. Respondents with diabetes reported more overall CAM use during the previous year (46.9% vs. 42%, P=0.049). A logistic regression model of patients with diabetes Type 2 indicated that CAM use was associated with higher self-assessed religiosity [Exp(B)=1.898, 95% CI for Exp(B) 1.02-3.529, P=0.043]. CAM use among patients with diabetes was also associated more with female gender, higher education, and age under 60. The positive association between CAM use and degree of self-assessed religiosity was further studied in sub-populations of Jewish and Arab patients with diabetes Type 2. A logistic regression model of the Jewish population indicated significant association between CAM use and higher religiosity [Exp(B)=3.668, 95% CI for Exp(B) 1.232-10.922, P=0.02]. CONCLUSION: Primary care physicians need to be aware of a possible association between religiosity and CAM use in patients with diabetes. Physicians may consider adding questions on CAM and religiosity to routine clinical interviews in order to enrich their dialog with diabetes patients.

Urologists' attitudes regarding information sharing with prostate cancer patients--is there a common ground for collaboration with family physicians?

Clinicians often fail to adequately meet prostate cancer patients' information needs, and patients may receive different kinds of information from their doctors. This study aims to describe urologists' attitudes regarding information sharing with prostate cancer patients and to compare these findings with the previously published attitudes of Israeli family physicians. A questionnaire (11 items) was mailed to 87 board-certified practicing urologists. Fifty-four physicians (66%) completed the questionnaires. Sixty-one percent of respondents stated that patients should be told the complete truth about their disease. Ninety-six percent of respondents felt competent at breaking bad news and stated they would discuss emotions with patients. The majority of physicians would provide general information when referring for a medical procedure, discussing treatment options or a patient's prognosis. Fifty-seven percent of respondents preferred that patients be autonomous in their decision making. Only 26% of respondents believed that family physicians should communicate medical information to patients at the preliminary diagnostic stages. There was no significant difference in the attitudes expressed by urologists and family physicians towards the amount of information they would share with prostate cancer patients and in their preferences regarding treatment decision making. Urologists in Israel recognize the importance of sharing information with prostate cancer patients. Although urologists share similar attitudes with family physicians, they do not recognize the role that family physicians play in caring for prostate cancer patients. Further studies are needed to design and implement effective ways to improve the communication and collaboration between urologists and family physicians for the benefit of prostate cancer patients.

Sex for seniors: how physicians discuss older adult's sexuality.

BACKGROUND: This study examined physicians' perspectives on sexuality in later life. METHODS: In-depth interviews were conducted among 38 physicians with various specialties and they were asked to discuss sexuality in later life within the medical context. RESULTS: Perceptions on older adult's sexuality emerged from the interviews were organized into three themes: What, why and how. What, referred to physician's definition to what role sexuality plays in later life and what is considered sex. Why, referred to the reasons why physicians assumed older adults experience sexual difficulties, and how these assumptions effect the diagnostic process. How, referred to how sexual difficulties were treated by physicians. Physicians employed a bio-medical approach when treating older, as compared to young adults with sexual dysfunction. CONCLUSIONS: The findings highlight a potential for differential treatment of older adults, based on age, rather than on other objective reasons.