[WHY EVERY HEALTH PROFESSIONAL NEEDS TO CONTEMPLATE MEDICINE DURING THE HOLOCAUST].

INTRODUCTION: A growing interest in the realization, understanding and lessons of medicine and physicians' behavior during the Holocaust, is noted in the last two decades. In this incomprehensible time, the dark and enlightened faces of medicine reached an unprecedented (and hopefully will not ever recur) climax. We learn of the criminal conduct of Nazi medicine and Nazi physicians on the one hand, and the noble, faithful to the Hippocratic oath, behavior of some prisoner physicians and nurses on the other hand. The understanding that learning about medicine during and beyond the Holocaust is a unique platform with exceptional impact on professional identity formation for present and future health professionals, is becoming clearer. In the present paper we will briefly delineate the historical background, its place in the professional discourse, describe a seminal conference that took place in Israel in 2017 that also launched the Galilee Declaration, and thoughts for the future. In Israel, Professor Shaul Shasha's initiative to hold a yearly meeting on medicine and health in the Holocaust in the Medical Center for the Galilee in Naharia, for the last 20 years, is central to this important subject. This paper is dedicated to him with profound gratitude.

How can medical schools contribute to bringing about health equity?

The role of medical schools is in a process of change. The World Health Organization has declared that they can no longer be ivory towers whose primary focus is the production of specialist physicians and cutting edge laboratory research. They must also be socially accountable and direct their activities towards meeting the priority health concerns of the areas they serve. The agenda must be set in partnership with stakeholders including governments, health care organisations and the public. The concept of social accountability has particular resonance for the Bar Ilan Faculty of Medicine in the Galilee, Israel's newest medical school, which was established with a purpose of reducing health inequities in the Region. As a way of exploring and understanding the issues, discussions were held with international experts in the field who visited the Galilee. A symposium involving representatives from other medical schools in Israel was also held to extend the discourse. Deliberations that took place are reported here. The meaning of social accountability was discussed, and how it could be achieved. Three forms of action were the principal foci - augmentation of the medical curriculum, direct action through community engagement and political advocacy. A platform was set for taking the social accountability agenda forward, with the hope that it will impact on health inequalities in Israel and contribute to discussions elsewhere.

Hospital-community interface: a qualitative study on patients with cancer and health care providers' experiences.

BACKGROUND: Patients with cancer must deal with complex and fragmented healthcare systems in addition to coping with the burden of their illness. To improve oncology treatment along the care continuum, the barriers and facilitators for streamlined oncologic care need to be better understood. PURPOSE: This study sought to gain insight into the hospital-community interface from the point of view of patients with cancer, their families, and health care providers on both sides of the interface i.e., the community and hospital settings. METHODS AND SAMPLE: The sample comprised 37 cancer patients, their family members, and 40 multidisciplinary health care providers. Twelve participants were interviewed individually and 65 took part in 10 focus groups. Based on the grounded theory approach, theoretical sampling and constant comparative analyses were used. RESULTS: Two major concepts emerged: "ambivalence and confusion" and "overcoming healthcare system barriers." Ambiguity was expressed regarding the roles of health care providers in the community and in the hospital. We identified three main strategies by which these patients and their families overcame barriers within the system: patients and families became their own case managers; patients and health care providers used informal routes of communication; and nurse specialists played a significant role in managing care. CONCLUSIONS: The heavy reliance on informal routes of communication and integration by patients and providers emphasizes the urgent need for change in order to improve coordinating mechanisms for hospital-community oncologic care.

Primary care physicians' use of an electronic medical record system: a cognitive task analysis.

OBJECTIVE: To describe physicians' patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient-doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular. DESIGN: Cognitive task analysis using semi-structured interviews and field observations. PARTICIPANTS: Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel. RESULTS: The comprehensiveness, organization, and readability of data in the EMR system reduced physicians' need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient's chart. EMR use interfered with patient-doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians' communication skills also helped. CONCLUSIONS: There is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians' offices and by enhancing physicians' computer and communication skills.

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

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

Evaluating primary care doctors' evidence-based medicine skills in a busy clinical setting.

RATIONALE, AIMS AND OBJECTIVES: To date, primary care doctors' (PCDs) evidence-based medicine (EBM) skills have rarely been studied. We conducted a cross-sectional study to evaluate PCDs' practical EBM skills and to determine risk markers associated with these skills. METHODS: The study sample consisted of 70 PCDs (70.7% response rate) practising in a busy urban setting from a large health maintenance organization. Participants were given a short validated questionnaire gauging attitudes, barriers, online medical resources utilization, as well as demographic and personal characteristics. Additionally, doctors completed an online and written exam evaluating their ability to formulate clinical questions, and retrieve medical information efficiently. Data analysis was performed using both bivariate and multivariate analysis (linear regression). RESULTS: PCDs found it difficult to formulate clinical questions both in the written and online exam, mostly neglecting to mention the Patient and Comparison components of PICO (patient, intervention, comparison and outcome). Search strategies primarily dispensed with the use of MeSH terms, ignoring appropriate limits. Doctors final scores were low (score = 41.5/100, SD = 16.2). In bivariate analysis clinical experience was negatively correlated with the final score (r = -0.36, P = 0.01), and specialists' scores were significantly higher than general practitioners' scores (46.7/100 and 31.5/100 respectively, P < 0.001). In multivariate analysis, doctors specialization was the only statistically significant predictor of the final score (B = 12.74, P = 0.002), while controlling for participating in a prior EBM course. CONCLUSIONS: This study emphasizes the need for enhancing PCDs practical EBM skills. Future research and interventions should focus on this population emphasizing the specific needs of subpopulations (i.e. general practitioners and doctors without previous EBM training).

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

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

[The Objective Structured Clinical Examination and its potential applications as an assessment and feedback tool for IDF primary care physicians--a pilot study].

BACKGROUND: In recent years, the Israel Defense Forces IDF developed special training programs for junior military physicians at the beginning of their service and CME courses for senior military physicians. The Objective Structured Clinical Examination (OSCE) is a well established assessment tool in medical education that can be of vast use in military training programs for primary care physicians. AIM: To evaluate the OSCE as an assessment tool of military primary care physicians. METHODS: Forty-one military primary care physicians completed a 10-station OSCE. The clinical scenario choices were based on the most prevalent problems in the annual statistics of the Israeli Medical Corps between the years 1988-1998. Each station consisted of two parts: a doctor-SP (standardized patient) encounter and a written exercise. Both parts were evaluated by checklists designed and validated by a committee of OSCE experts and senior military physicians. RESULTS: The overall reliability of the exam was alpha = .88. The examinees highly valued the relevance of the scenarios to their every day practice (4.38 out of 5.0) and the reliability of the standardized patients (4.0 out of 5.0). A total of 92% request feedback on their performance. CONCLUSIONS: This pilot study found the OSCE to be a feasible, valid and reliable tool that can serve to assess the capability of physicians to deal with major issues in military primary health care. The OSCE can also play a major role in structured feedback provided to these physicians.

Quality assessment in primary military clinics of the Israel Defense Forces Northern Command.

OBJECTIVE: To assess the quality of care provided in primary military clinics. METHODS: A standardized assessment tool was used, with medical record audits and tracers (minimal clinical criteria for proper care of common conditions), peer-review observations of medical encounters, assessments of organization and administration, and patient satisfaction and physicians' occupational stress questionnaires. RESULTS: Forty-three clinics and 113 physicians were assessed. Tracers were high for management of upper respiratory infections and low for low back pains and mental problems. The average encounter time was 9 minutes, and 25% of medical encounters resulted in referrals to specialists. Regular physicians performed better than reservists. Surgeons performed worst as primary health care providers. Female physicians did better than male physicians. The integration of new immigrant physicians was successful, and they expressed less occupational stress. Smaller clinics were better, with longer encounter times and better patient satisfaction scores. CONCLUSIONS: Quality assessment of primary health care is feasible in the military system, providing useful information for future improvement.

Ability of primary care physician's to break bad news: a performance based assessment of an educational intervention.

OBJECTIVE: We have previously described a breaking bad news (BBN) training program for primary care physicians [Ungar L, Alperin M, Amiel GE, Beharier Z, Reis S. Breaking bad news: structured training for family medicine residents. Patient Educ Couns 2002;48:63-68]. In this paper, we present the assessment of an educational intervention aimed at improving this important skill. METHODS: The assessment tool was an eight station objective structured clinical examination (OSCE) utilizing standardized patients (SPs). Intervention and control groups of 17 general practitioners (GP) each were evaluated before and after an educational intervention, or a Balint group (control). RESULTS: Intervention group GPs significantly increased their average grade on the post-test as compared to the pre-test (58.5, S.D. 12.7 versus 68.4, S.D. 9.2), effect size 0.94. Improvement in the control group was minimal (pre-test 57, S.D. 10.4 versus 58.1, S.D. 9.5 for the post-test), effect size 0.23. Reliability of the OSCE was alpha = 0.81. CONCLUSION: The performance assessment used in this study proved to be a reliable and valid tool to assess the ability of physicians to break bad news. It provided evidence of the effectiveness of the intervention. PRACTICE IMPLICATIONS: BBN training can and should be evaluated by valid and reliable measures. SPs can serve as reliable evaluators of BBN training.

Performance assessment of community-based physicians: evaluating the reliability and validity of a tool for determining CME needs.

PURPOSE: To evaluate the reliability, validity, and feasibility of the Physician Assessment in Medical Practice (PAMP) as a means of determining the CME needs of practicing, community-based physicians. METHOD: A group of 45 randomly selected community-based physicians (19 certified family physicians and 26 general practitioners) affiliated with the Department of Family Medicine at Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel, volunteered to participate in the study, conducted in 1997. All participants took a ten-station, performance-based examination designed to closely represent the physicians' work settings. At each station, a different medical problem was presented by a standardized patient. Physician-candidates' performances were assessed by physician-examiners using global ratings. The following performance domains were assessed: information gathering, diagnosis and management plan, and communication skills. A CME needs assessment score was determined for each of the participants and a CME level to meet the needs of the physician was recommended. RESULTS: Overall reliability of the examination was high (.87), with domain reliabilities ranging from.76 to.87. Reliability of the examiners' judgments of the physicians' competence was.66. All the stations' validity scores were significant, and differences in performances between family physicians and general practitioners demonstrated construct validity of the test results. Overall, the cost of running the examination was U.S. $250 per physician-candidate. CONCLUSIONS: Using the PAMP to determine CME needs of community-based physicians was found to reliable, valid, and feasible, and the cost per physician-candidate was not excessive. Performance results provided indepth information for use by both the individual physician and providers of CME programs.

Advances in the field of low back pain in primary care: a report from the fourth international forum.

STUDY DESIGN: Review of advances in the primary care research on low back pain (LBP) from a unique international forum, and analysis of open-ended questionnaires from participants. SUMMARY OF BACKGROUND DATA: LBP continues to be one of the most common and challenging problems in primary care. It is associated with enormous costs in terms of direct health care expenditures, and indirect work and disability-related losses. OBJECTIVE: To ascertain the current status and state of the art regarding LBP in primary care. METHODS: Four reviewers independently assessed the content and implications of presentations at the Fourth International Forum for Primary Care Research on LBP, pooled the data, and then augmented it with open-ended questionnaires completed by 35 participants. RESULTS: The Fourth Forum documented the field's emergent new paradigm-a transition from thinking about back pain as a biomedical "injury" to viewing LBP as a multifactorial biopsychosocial pain syndrome. The paradigm shift has occurred in the context of increased interest in evidence-based medicine regarding LBP in primary care. The Forum demonstrated the strides taken in moving from research and evidence gathering, through guidelines and policy formulations and finally to the dissemination and implementation imperative. There was an increasing confidence among the Forum researchers that LBP can be managed successfully in primary care settings through a combination of encouraging activity, reassurance, short-term symptom control, and alteration of inappropriate beliefs about the correlations of back pain with impairment and disability. There is also recognition that a wide range of international, evidence-based guidelines now exists that have very similar messages. CONCLUSIONS: The Fourth Forum reflected a major shift in the conceptualization of LBP in primary care and an increased emphasis on implementation and dissemination of LBP research findings and clinical guidelines. Although there is a wide array of challenges ahead, the Fourth Forum provided a clear message regarding the need to focus research energies on changing practitioner behavior.