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.

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.

[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.

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 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.

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.

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.

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.

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).

Challenging the present definition of "normal" vitamin D levels obtained by a single blood test. Can we develop a formula to predict vitamin D levels in the 4 seasons from a single season's measure?

Publications on the health effects of vitamin D (25(OH) D) had almost triplicate in the last 10years, not only for its known "calcemic effects" (calcium, phosphor, PTH), but for the more recent findings on its "non-calcemic effects" (all-cause and cardiovascular mortality, and relation with certain types of cancer). Part of these publications deal with the definition of what is a "normal" circulating level of 25(OH) D that may distinguish between health and disease. The literature also deals with seasonal variations of vitamin D, showing levels that rise in summer and fall in winter and with DBP phenotypes and geographical location that affect seasonality of 25(OH) D measurements. Despite the knowledge of the existence of these phenomena many studies on vitamin D fail to acknowledge the time of the year the blood sample was extracted. Thus, when we compare results from different studies without defining the season that the samples were drawn, we compare incomparable figures. Furthermore, it is quite absurd to define "normal levels" as a static measure (over or under a certain value) using a single blood test when the value measured is known to change with seasons. Knowing that people have different vitamin D levels in different seasons of the year, we should ask ourselves which of these measurements should be used to define a "real" or "normal" level? Is it the lower one? Is there a "mean measure" that should be used for this matter? If yes, how do we obtain it? Do we have to make 4 seasonal measurements in each patient? Alternatively, might there be a possibility of developing a formula to help us obtain the mean from a single season's measure or one season's prediction from another season's measurement? And knowing that DBP phenotypes and geographical location affect seasonality of 25(OH) D measurements; shouldn't we include this in the equation? In this article I will discuss the hypothetical existence of an Individual Mean Annual vitamin D level that I will call the "IMAD level" and a recovery formula "RF" that may be used to calculate this mean having one single measure (in any of the 4 seasons) and to predict any season's value from another season's measurement. IMAD levels should be obtained in the two main DBP phenotypes, taking into account the geographical location of the test.

Medical students' and interns' interest in orthopedic surgery: the gender factor.

OBJECTIVE: There is an extremely small proportion of female medical students choosing to specialize in orthopedic surgery. The aim of the study was to assess medical students' and interns' interests and perceptions of orthopedic surgery and explore why women are not interested in orthopedic surgery. SETTING: Questionnaires were distributed to final-year medical students and interns assessing their interests and perception of orthopedic surgery. PARTICIPANTS: Final-year medical students and interns. RESULTS: Responses were obtained from 317 students and 199 interns. Among the medical students, 15% were interested in orthopedic surgery, but only 2% were women. Both male and female students perceived orthopedics as an "action"-packed, procedure-based profession, providing instant gratification, time in the operating room, high income, and the option for private practice. Female medical students considered it boring. Among interns, 11% were interested in orthopedic surgery; however, only 2% were women. When compared with the interns who were not interested in orthopedic surgery, a greater number of the interns interested in orthopedic surgery rated time with family and a procedure-intensive profession as important. Female students and interns were also interested in other surgical fields. CONCLUSIONS: The increasing majority of women among medical students will reshape the future of physician workforce by dictating changes in workforce participation, working conditions, and intercollegial relationships. Orthopedic surgery will need to adapt to these realities.

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.

Israeli medical students' perceptions of six key medical specialties.

BACKGROUND: Choosing a medical specialty requires medical students to match their interests and social-cultural situations with their perceptions of the various specialties. OBJECTIVES: Examine Israeli 6th-year medical students' perceptions of six key specialties: pediatrics, orthopedic surgery, anesthesiology, obstetrics/gynecology, general surgery and family medicine. METHODS: Questionnaires distributed to 355 6th-year students from three successive classes (2008-2010) of 6th-year students at the Hebrew University - Hadassah School of Medicine, Jerusalem, Israel and the 2010 class of the Ben Gurion University School of Medicine, Be'er Sheva, Israel. RESULTS: Responses were obtained from 234 students, for a response rate of 66%. Pediatrics and obstetrics/gynecology were the specialties most often under positive career consideration by individual students. Anesthesiology and general surgery were least often under positive career consideration and were viewed as being in a workforce crisis. Pediatrics and family medicine, found to be especially popular among women, were perceived by 58% and 78% of respondents, respectively, as providing reasonable ratios of lifestyle to income. None of the students thought the same about general surgery and only 28% thought so about anesthesiology. Pediatrics and obstetrics/gynecology were reported to afford a controllable lifestyle by 63% and 8%, respectively, With respect to positive career considerations and lifestyle perceptions, there were no differences between the opinions of men and women students. Differences between genders arose in responses to queries of whether a specialty was interesting and challenging. Women were more likely than men to perceive pediatrics and family medicine as interesting and challenging while men were more likely to think that general and orthopedic surgery are interesting and challenging. CONCLUSIONS: Knowing the medical students' perceptions of the various specialties should help in understanding the maldistribution of physicians among the various specialties. Such data can also be an important input into the efforts of the healthcare leadership to promote a specialty distribution that matches the population's evolving needs.

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.

Medical specialty considerations by medical students early in their clinical experience.

BACKGROUND: Specialty selection by medical students determines the future composition of the physician workforce. Selection of career specialties begins in earnest during the clinical rotations with exposure to the clinical and intellectual environments of various specialties. Career specialty selection is followed by choosing a residency program. This is the period where insight into the decision process might help healthcare leaders ascertain whether, when, and how to intervene and attempt to influence students' decisions. The criteria students consider important in selecting a specialty and a residency program during the early phases of their clinical rotations were examined. METHODS: Questionnaires distributed to fifth-year medical students at two Israeli medical schools. RESULTS: 229 of 275 (83%) questionnaires were returned. 80% of the students had considered specialties; 62% considered one specialty, 25% two, the remainder 3-5 specialties. Students took a long-range view; 55% considered working conditions after residency more important than those during residency, another 42% considered both equally important. More than two-thirds wanted an interesting and challenging bedside specialty affording control over lifestyle and providing a reasonable relationship between salary and lifestyle. Men were more interested in well-remunerated procedure-oriented specialties that allowed for private practice. Most students rated as important selecting a challenging and interesting residency program characterized by good relationships between staff members, with positive treatment by the institution, and that provided much teaching. More women wanted short residencies with few on-calls and limited hours. More men rated as important residencies affording much responsibility for making clinical decisions and providing research opportunities. More than 50% of the students considered it important that their residency be in a leading department, and in a large university medical center. Only 5% considered it important to do their residency in the country's peripheral areas, while 30% reported interest in a residency in the country's center. CONCLUSIONS: The fifth year of a six-year medical school is an opportune time to provide students with information and guidance on the various specialties and selecting a residency program as they begin to solidify their perceptions and ideas about the various specialties. This study serves as an impetus to medical educators and healthcare leaders to become interested in students' career selection.

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.

Benefits of active participation of family physicians in geriatric consultations.

BACKGROUND: Geriatric consultation services are generally beneficial in improving the health and well-being of the elderly. We prospectively studied whether the active participation of family physicians (FPs) in the process of geriatric consultation would improve implementation rates and benefit the health care of the elderly. METHODS: We carried out a comparative prospective intervention study in three urban academic family medicine clinics. Patients in the control clinics were evaluated by the consultant geriatrician, and a summary of the findings and recommendations were presented to the FP in a brief meeting. In the intervention clinic, the referring FP joined the geriatrician throughout the geriatric assessment. The percentage of implementation of suggested recommendations was evaluated. Information regarding the utilization of health services was provided from computerized data. RESULTS: Of the 212 patients included in the study, 107 were in the intervention group and 105 were controls. The overall rate of implementation was significantly higher for patients in the intervention group (329/445; 73.9%) than for patients in the control group (232/387; 59.9%), P < 0.0001. In the year after the geriatric assessment, those in the intervention group visited the FP less often. CONCLUSIONS: A model co-consultation actively involving the FP in the process of assessment of the older patient by the geriatrician improves the degree of implementation of recommendations without an increase in related heath care utilization and costs. This model should be further developed and studied.

Depressive symptomatology as a risk factor for increased health service utilization among elderly patients in primary care.

Depression may play an important role in determining frequent physician visits in the older population. Our aim is to examine the relationships between socio-demographic variables, co-morbidity, memory complaints, functional status, depressive symptomatology, and health care utilization among community dwelling older patients. The study was conducted in urban primary health care clinics in Beer-Sheva, Israel. Two groups were identified: low care utilizers (LCU), with ≤ 6 visits to family physicians (FP)/year and high care utilizers (HCU) with ≥ 16 visits to FP/year. Data were collected during a structured face-to-face individual interview. The study population included 180 patients, of them 86 (47.7%) were LCU and 94 (52.2%) were HCU. In all clinical measurements the HCU group indicators were statistically significant worse off than the LCU group: average depressive symptoms (5.6 vs. 2.5, p<0.01), memory complaints (57.5% vs. 23.3%, p<0.01), Barthel Index (BI) (89.9 vs. 96.0, p<0.001), OARS (10.8 vs. 12.5, p<0.01), and co-morbidity: total cumulative score (TCS) of Charlson comorbidity index (CCI) (2.2 vs. 1.3, p<0.01). Our study raises the possibility that at least one of the reasons for over-utilization of health services by older residents in the community is depressive symptomatology.