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.

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.

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.

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.

When sex meets age: Family physicians' perspectives about sexual dysfunction among older men and women: A qualitative study from Israel.

BACKGROUND: Gender differences in relation to sexual functioning among older adults have received very little research attention, although the ageing process is likely to be characterized by difficulties in sexual functioning among both women and men. OBJECTIVES: The purpose of this qualitative research is to examine and understand the perceptions of family physicians, and the differences in their attitudes regarding male and female patients. METHOD: Qualitative interviews with family physicians were conducted between August 2017 and December 2017. Sixteen family physicians participated in the study, aged 36-64; most were born in Israel and half of them were women. Twelve physicians were Jewish, two were Christian and two were Muslim. Nine work in rural practices and seven work in urban practices. We used in-depth, semi-structured, face-to-face interviews. The interviews were recorded, transcribed and analysed by three researchers using content analysis. RESULTS: The analysis of the interviews revealed two main themes: (1) Differences as perceived by family physicians: men are perceived as being interested in engaging in full sexual relations, including penetration, while among women, the main need is focused on the relationship and intimacy. (2) Gender differences regarding seeking a solution through the family physician. Family physicians reported that most of the patients who seek solutions regarding sexual dysfunction in old age are men with impotence problems. Family physicians perceived that women seek out solutions less frequently, some because they are afraid their relationship will suffer if they do not continue having sex with their partners. CONCLUSION: Men and women were seen as having different motivations for engaging in sex and different needs from physicians.

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.

Video or In-Clinic Consultation? Selection of Attributes as Preparation for a Discrete Choice Experiment Among Key Stakeholders.

INTRODUCTION: Video consultations (VCs) provide increased accessibility of primary care to remote areas and overall improved care for chronic patients. They also contribute to higher patient satisfaction and improved resource management. Despite these benefits, VC integration into the health system is complex and slow. Understanding the VC-related preferences of three key stakeholders-patients, primary care physicians (PCPs) and policy makers (PMs)-is crucial for achieving optimal implementation. OBJECTIVE: The aim of this study was to select relevant attributes and levels for a discrete choice experiment (DCE) of stakeholders' choice-VC or traditional in-clinic consultation (I-CC) in primary care. METHODS: Ten semi-structured focus group interviews and 24 semi-structured individual interviews were conducted. Data analysis was performed inductively, using a thematic content analysis method. An attribute-ranking exercise was then conducted based on the results gleaned from the interviews. RESULTS: The most important attributes when choosing either VC or I-CC, for both patients and PMs, were: (1) time to next available appointment; (2) time in line before consultation; (3) relationship to PCP; and (4) quality of consultation. For PCPs, the most important attributes were: (1) time in line before consultation; (2) patient's self-management ability; (3) consultation purpose; (4) quality of consultation. CONCLUSIONS: This qualitative study identified attributes and levels for a DCE quantitative stage among three key stakeholder groups. It adds to the literature of examples of developing DCE attributes, and to literature about the stakeholder benefits in the area of telemedicine in healthcare.

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.

Knowledge and attitudes about mental health among older immigrants from the former Soviet Union to Israel and their primary care physicians.

Previous studies have documented a high prevalence of psychological distress and mental illness among older immigrants from the former Soviet Union (FSU) in Israel. Yet, this population rarely seeks help from mental health providers. The present study aimed to identify beliefs and attitudes about depression and anxiety among older immigrants from the FSU treated in primary care, and among their primary care physicians, who were also FSU immigrants. The study used focus group (FG) interviews with primary care patients (n = 12) and physicians (n = 23). The interviews were transcribed and analyzed using open thematic coding. Three main themes were identified: a) avoidance of discussion of mental health and stigma regarding mental illness; b) expectations to control one's mental state; and c) limited opportunities to acquire knowledge about Western mental health. Primary care physicians recognized the barriers facing their older immigrant patients concerning mental health diagnosis and treatment. Yet, due to work overload, their ability to assist older immigrants was limited. The findings suggest that older immigrants from the FSU might benefit from mental health information and exchange of ideas about Western mental health.

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.

Patient's Utilization of Primary Care: A Profile of Clinical and Administrative Reasons for Visits in Israel.

BACKGROUND: Data on patients' utilization of health services in primary care is relevant to planning healthcare. Data may be collected by numerous methods, but obtaining a true picture of content of care has practical difficulties. OBJECTIVES: To describe patient's reasons for visits to primary care physicians (PCPs) as presented by the patient; and to examine the effect of patient-, doctor- and clinic-related variables on the reasons for the visit. METHODS: Visits to PCPs were observed by peer doctors during 2014, at primary care clinics in Israel. Data were collected on characteristics of physicians, patients, clinics, type of visit, and reasons for visit. RESULTS: Eleven physicians from 7 clinics participated in the study. Data were gathered from 327 visits. Patients visited for a wide variety of reasons. The most common acute complaints were upper respiratory symptoms, gastrointestinal, skin symptoms, and back and neck problems. The most common chronic complaints were hypertension and diabetes. Patients presented with administrative requests in 36% of visits; 15% were for solely administrative issues. A total of 26.6% of visits included requests for blood tests or discussion of tests. Patients initiated preventive medicine issues in 5% of visits. Visits for chronic problems were directly correlated with patient age and the extent of acquaintance with the physician. Gender-associated differences were also found: women were more likely to visit for a new medical problem than men, while men were more likely to visit for known or chronic problems. CONCLUSIONS: Patients visit their PCP for a wide variety of reasons, often during the same visit. Patients refer for administrative requests in about a third of visits. They initiate preventive care infrequently (1 out of 20 visits). To further characterize patient utilization of primary care, a broader study needs to be performed.

Effect of Magnesium Oxide Supplementation on Nocturnal Leg Cramps: A Randomized Clinical Trial.

Importance: Magnesium supplements are widely marketed for prophylaxis of nocturnal leg cramps (NLC) despite no evidence of significant benefit. Objective: To determine whether magnesium oxide is better than placebo for NLC prophylaxis. Design, Setting, and Participants: A randomized, double-blind, placebo-controlled clinical trial of 2 weeks eligibility screening followed by 4 weeks of treatment was conducted in northern Israel, from February to October 2013. An intention-to-treat data analysis was performed from March 22, 2014, to April 17, 2016. We used a volunteer sample of community-dwelling individuals experiencing NLC, 21 years or older, with 4 or more documented episodes of NLC during 2 weeks of screening. Interventions: Capsules containing either magnesium oxide or a similar-looking placebo to be taken orally, once daily at bedtime for a period of 4 weeks. Main Outcomes and Measures: The primary outcome was the difference in the mean number of NLC per week between the screening and treatment phases. Secondary outcomes included severity and duration of NLC, quality of life, and quality of sleep. Results: Of the 166 volunteers, 72 (43%) were excluded, of whom 15 declined to participate and 57 did not meet the inclusion criteria. Of the 94 individuals (39% male; mean [SD] age, 64.9 [11.1] years) randomly assigned to magnesium oxide (48) or placebo (46), 6 did not complete the study protocol (3 in each group). Mean (SD) change of NLC was -3.41 (4.05) (from 7.84 [5.68] to 4.44 [5.66]) and -3.03 (4.53) (from 8.51 [5.20] to 5.48 [4.93]) per week in the magnesium oxide and placebo groups, respectively, a difference between groups of 0.38 (0.48) NLC per week (P = .67 in an intention-to-treat analysis). There were no between-group differences in the severity and duration of NLC, quality of life, or quality of sleep. Conclusions and Relevance: Oral magnesium oxide was not superior to placebo for older adults experiencing NLC. The decrease in the mean number of NLC per week, from the screening to the treatment phase in both groups, is probably a placebo effect that may explain the wide use of magnesium for NLC. Trial Registration: clinicaltrials.gov Identifier: NCT01709968.

Poor glycemic control as a reason for referral of diabetes patients to specialists in Israel.

AIMS/INTRODUCTION: Family physicians face the dilemma of when to refer patients with diabetes to specialists. This study examined attitudes of family physicians to referring patients with poor glucose control to diabetes specialists. MATERIALS AND METHODS: At continuous medical education courses, family physicians were asked to respond anonymously, as to whether they generally manage the diabetes of their patients, and specifically those with poor glycemic control (HbA1c>9.0%). RESULTS: Of 470 respondents, 426 (90%) reported that they generally manage their patients' diabetes; 202 (43%) reported that they manage the diabetes of patients with HbA1c>9.0%. Board certification in family medicine and affiliation to a health maintenance organization, but not sex, age, years of professional experience, or the proportion of patients with diabetes at their clinics, were associated with referral practices. CONCLUSIONS: Family medicine residency and organizational support appear to promote treatment by family physicians of patients with poorly controlled diabetes in the primary care setting.

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.

Primary care physicians' role perception and self-reported performance in glaucoma care: a survey study.

BACKGROUND: Glaucoma is a leading cause of blindness. The participation of primary care physicians (PCPs) in glaucoma care may improve health outcomes for glaucoma patients. OBJECTIVES: To investigate PCPs' attitudes towards their role in glaucoma care, perceived barriers, and self-reported performance in glaucoma management. METHODS: PCPs working in the Haifa and Western Galilee District of Clalit Health Services, Israel's largest Health Maintenance Organization (HMO) were asked to complete a self-administered structured questionnaire. Physicians were asked to rate their agreement with statements describing the PCP's role in glaucoma care, and to state how often they behave accordingly in their practice. In addition, physicians were asked to rate the extent that factors such as time constraints and knowledge gaps impede their performance in glaucoma care. RESULTS: Eighty-two physicians completed the questionnaire. The majority thought that PCPs have a major role in early detection of glaucoma (99 %), discussing the importance of adherence to treatment (93 %), and encouraging patients to make regular visits to their ophthalmologist (99 %). However, only 30 % reported asking patients about family history of glaucoma, 64 % reported discussing adherence to treatment, and only 35 % stated that they explain how to use eye drops, while most of respondents (87 %) regularly provide refill prescriptions for glaucoma medications. Sixty percent claimed that during their residency they had not acquired adequate knowledge and competence to allow them to take proper care of glaucoma patients. The main barriers reported were lack of time (43 %), lack of knowledge regarding treatment options and recommended follow-up (46 %), and not being familiar with glaucoma medications' side effects (54 %). CONCLUSIONS: There is a gap between PCPs' perceptions of their role in glaucoma care and their report on actual performance in early detection and management of glaucoma. Further research is needed to develop and assess interventions that aim at closing this gap.

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.

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.