Burnout among family medicine residents: a cross-sectional nationwide study.

BACKGROUND: In addition to pressures typical of other medical professions, family physicians face additional challenges such as building long-term relationships with patients, dealing with patients' social problems, and working at a high level of uncertainty. We aimed to assess the rate of burnout and factors associated with it among family medicine residents throughout Israel. METHODS: A cross sectional study based on a self-administered questionnaire. RESULTS: Ninety family medicine residents throughout Israel completed the questionnaire. The rate of clinically significant burnout, assessed by the composite Shirom-Melamed Burnout Questionnaire score, was 14.4%. In univariate analyses several personal and professional characteristics, as well as all tested psychological characteristics, showed significant associations with burnout. However, in the multivariable logistic regression only psychological work-related characteristics (work engagement, psychological flexibility (reverse scoring), and perceived work-related stress) were significantly associated with burnout at OR (95% CI) = 0.23 (0.06-0.60), 1.31 (1.10-1.71), and 1.16 (1.05-3.749), respectively. CONCLUSION: The integration of burnout prevention programs into academic courses during residency could explain the relatively low prevalence of burnout among family medicine residents in this study. Given the strong association of burnout with psychological characteristics, further investment in burnout prevention through targeted structured courses for residents should be encouraged.

Depression and Medicine Use among Older Adults during the COVID-19 Pandemic: The Role of Psychosocial Resources and COVID-19 Perceived Susceptibility.

A relationship was found between the COVID-19 pandemic and depression among older adults and between depressed mood and increased use of antidepressant medication among older adults during the pandemic. With the aim of broadening the understanding of these relationships, the study examined whether COVID-19 perceived susceptibility mediates the relationship between psychosocial resources (optimism and perceived social support) and depressive symptoms and medication use. Participants included 383 older adults (M = 71.75, SD = 6.77) reporting on socio-demographics, health characteristics, depression, optimism, social support, and COVID-19 perceived susceptibility. Medication use was retrieved from participants medical files. Lower optimism, lower social support, and higher COVID-19 perceived susceptibility were associated with greater depression, related with higher medication use. The findings emphasize the buffering effect of psychosocial resources on the adverse effects of depression affecting older adults during the COVID-19 pandemic, and consequently, the increased use of medication in this population. Practitioners should focus interventions on enhancing optimism and expanding social support among older adults. Moreover, interventions focused on alleviating depression among older adults should aim at improving perceptions of perceived susceptibility in the older population.

Sensory retraining for Central Post-Stroke Pain: A subgroup analysis within a randomized controlled trial.

BACKGROUND: Explicit Sensory Retraining (SR) has been suggested for pain management in several neuropathic pain syndromes. OBJECTIVES: To study the effectiveness of SR on Central Post Stroke Pain (CPSP) symptoms. METHODS: A preplanned subgroup of 23 subjects post-stroke reporting central pain were randomized within a larger study, to receive either explicit sensory discrimination retraining (SR) (in subgroup n = 11) or implicit repeated exposure to stimuli (RE) (in subgroup n = 12), applied to the lower limb. Pain intensity measured by VAS, measures of sensory ability; balance and gait activities; and participation were assessed by a blinded assessor at four points in time. RESULTS: A group*time interaction effect was demonstrated (p = 0.04) for VAS, as for the SR treatment group VAS decreased from 56/100 to 23/100. Nine out of eleven subjects in the SR group demonstrated positive response to treatment. Pain alleviation was maintained at follow-up. A similar interaction effect was found for tactile threshold (p = 0.03). Significant improvement was noted for all other variables with no group differences. CONCLUSION: This study provides preliminary evidence to the clinically relevant positive effect of explicit sensory retraining for subjects with CPSP. The positive effect on tactile threshold detection could potentially indicate pain alleviation mechanisms.

Explicit versus implicit lower extremity sensory retraining for post-stroke chronic sensory deficits: a randomized controlled trial.

PURPOSE: Sensory impairment post-stroke limits rehabilitation of balance and gait. This study aims to compare the effect of explicit sensory retraining (ESR) versus implicit repeated exposure (IRE) to stimuli of the lower extremity, assessing their effects on sensation, balance, and gait in individuals with chronic post-stroke sensory impairment. MATERIALS AND METHODS: A two-arm parallel double-blind multicenter randomized controlled trial was conducted in physical therapy outpatient clinics. Volunteers with chronic sensory impairment post-stroke participated in 10 sessions of 45 min ESR or IRE, according to a detailed protocol. Outcome measures assessed sensation, balance, mobility, and participation. RESULTS: A total of 64 participants were recruited (ESR, n = 34; IRE, n = 30). The intention-to-treat pre-post analysis demonstrated clinically meaningful changes for both interventions (10-31% improvement for the various measures), with no between-group difference or time × group interaction. The effect size for the time effect varied, with the largest being 0.63 for the miniBEST. CONCLUSIONS: Sensory rehabilitation treatment by either ESR or IRE led to similar clinically significant changes in the performance of the lower extremity and participation in subjects with sensory loss post-stroke. Both treatment protocols are easy to implement in an outpatient clinic. . CLINICALTRIALS.GOV REGISTRATION: NCT01988220. Implications for rehabilitationStandardized, structured, sensory-focused training can improve balance and gait in subjects with chronic post-stroke sensory impairment.Both explicit and implicit learning-based sensory protocols focused on the lower extremity effectively improved balance, mobility, and gait abilities, resulting in enhanced participation of individuals in the chronic post-stroke phase.A series of ten 45-minute treatment sessions in outpatient clinics lead to clinically significant improvements.

Direct Oral Anticoagulants in Special Patient Populations.

Anticoagulants are a cornerstone of treatment in atrial fibrillation. Nowadays, direct oral anticoagulants (DOACs) are extensively used for this condition in developed countries. However, DOAC treatment may be inappropriate in certain patient populations, such as: patients with chronic kidney disease in whom DOAC concentrations may be dangerously elevated; frail elderly patients with an increased risk of falls; patients with significant drug-drug interactions (DDI) affecting either DOAC concentration or effect; patients at the extremes of body mass in whom an "abnormal" volume of distribution may result in inappropriate drug concentrations; patients with recurrent stroke reflecting an unusually high thromboembolic tendency; and, lastly, patients who experience major hemorrhage on an anticoagulant and in whom continued anticoagulation is deemed necessary. Herein we provide a fictional case-based approach to review the recommendations for the use of DOACs in these special patient populations.

Perceptions among diabetic patients in the ultra-orthodox Jewish community regarding medication adherence: a qualitative study.

BACKGROUND: Promoting a healthy lifestyle and achieving strict adherence to medical treatment among patients with diabetes are key objectives in public health. Yet health behaviors are often culturally driven, especially in closed religious communities. This study seeks to reveal key cultural-religious factors, attitudes and behaviors characterizing the lifestyle in one such closed community-the ultra-Orthodox Jewish community-by understanding the attitudes of ultra-Orthodox patients with diabetes toward coping with their illness and the factors impacting their adherence to medicinal treatment. METHOD: Qualitative interviews were conducted with 16 ultra-Orthodox patients with diabetes using a semi-structured, in-depth questionnaire. RESULTS: Three main themes emerged: 1) "The disease as a secret": Hiding the disease among patients with diabetes in ultra-Orthodox society; 2) "Distinguishing between sacred and secular occasions": ultra-Orthodox diabetes patients distinguish between treatment adherence on weekdays and treatment adherence on holidays or special occasions; 3) "Ask the rabbi": In cases of dilemmas that involved conflicts between halakhic rulings and doctors' instructions, the rabbi's decision was usually the final one. CONCLUSIONS: The findings of this study may help provide an in-depth understanding of the obstacles and motives of ultra-Orthodox patients in adhering to medicinal treatment of diabetes in particular and to medicinal treatment in general, thus helping family physicians who treat this population provide optimal and appropriate treatment.

Depression and Health-Related Quality of Life Among Elderly Patients during the COVID-19 Pandemic in Israel: A Cross-sectional Study.

AIM: This study aims to assess how optimism, social support, and perceived susceptibility are associated with depressive symptoms and health-related quality of life among elderly patients during the COVID-19 pandemic in Israel. METHODS: In a cross-sectional study, 256 participants age 60 through 95 completed the following self-administered questionnaires: Perceived Susceptibility, Life Orientation Test (LOT-R), Multidimensional Scale of Perceived Social Support (MSPSS), Symptoms of Depression (CES-D) and health-related quality of life (SF-12v2 Health Survey). Data were collected from June to July 2020, 3 months after the COVID-19 state of emergency was declared in Israel. Participants were interviewed by family medicine residents via telephone. Statistical analyses included Pearson correlations, t-tests between groups, regression analyses, and Hayes' PROCESS to analyze a moderated mediation model. RESULTS: Of the elderly participants, 37.5% were classified as having depression. Optimism, social support and health-related quality of life were positively associated. Higher optimism and social support were related to lower perceived susceptibility and lower depression. Results of a multivariate regression explained 29% of the variance in depression and 19% of the variance in health-related quality of life. The relationships assessed by 4 Process models were significant, such that higher optimism and social support were related to lower perceived susceptibility, which in turn was related to higher depression and lower health-related quality of life. CONCLUSIONS: Optimism and social support may be effective in coping with challenges and buffering depression. Perceived susceptibility may mediate the association of optimism and social support with higher depression and lower health-related quality of life. The conclusions of this study underscore the need to treat depression among older adults during this period. Hence, healthcare providers should also support elderly patients living at home. In giving this type of help, healthcare providers should strive to increase social support and optimism among older adults.

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.

Lower Extremity Position Test: A new clinical quantitative assessment tool of proprioception post stroke.

OBJECTIVE: To develop a quantitative, inexpensive and easy to use tool, for assessing proprioception of the lower extremity of individuals post-stroke, and examine its test-retest reliability and known-groups validity. METHODS: The Lower Extremity Position Test was developed. Testing procedure: seated subjects were asked to reproduce 12 cm or 22 cm distances on a plastic surface, by verbally stopping passive movement of the foot produced by the tester. The deviation from the target point was measured as the mismatch score. Fifty one subjects post-stroke (n = 51) participated in prospective test-retest assessment. The tests were performed one week apart by a single assessor, in physical therapy out-patient clinics. The t-test, ICC and Bland-Altman tests were used to determine known-groups validity by determining leg differences and test-retest reliability. RESULTS: Post-stroke involved foot demonstrated significantly higher mismatch scores then the uninvolved foot did (p < 0.0001). Good test-retest reliability was demonstrated for the involved leg for both 12 cm and 22 cm distances (ICC = 0.79 and 0.85, respectively). The 95% repeatability ranges were leg related. CONCLUSIONS: The Lower Extremity Position Test (LEPT) is a newly-developed testing tool with good clinical utility, reliable in post-stroke population and has known-group validity (involved versus uninvolved foot).

Assessment of texture discrimination ability at the sole of the foot in subjects with chronic stroke compared with young and elderly subjects with no neurological deficits: a reliability and validity study.

PURPOSE: To examine validity and test-retest reliability of a sensory test developed to evaluate ability of elderly subjects with/out a stroke to discriminate between textures with the sole of their foot. METHODS: Subjects poststroke, old adults and young subjects were tested twice. Twelve materials relevant to foot function (e.g., gravel, sand) were used. Blindfolded subjects were requested to discriminate with the sole of each foot one outstanding texture among three textures presented in each of 12 subtests. ANOVA, ICC and Bland-Altman tests were used to determine group/leg differences and test-retest reliability. RESULTS: Discrimination ability of the involved lower extremity poststroke is significantly reduced. Ability in individuals with no neurological impairment is age related. Good test-retest (ICC = 0.81) reliability was demonstrated for the impaired foot of subjects poststroke. The 95% repeatability ranges were age related with the highest range demonstrated for the involved foot poststroke. A significant fair negative correlation was demonstrated between texture discrimination ability and tactile detection threshold measured by Semmes-Weinstein monofilaments for the involved foot in poststroke subjects. CONCLUSION: This newly developed assessment tool demonstrates concurrent and known-groups validity and is reliable for determining texture discriminative ability of the foot in individuals post-stroke and in older adults with no neurological impairment. Implications for rehabilitation The texture discrimination test presented here is a valid and reliable tool, providing quantitative assessment of sensory function at the sole of the foot in older adults with no neurologic deficits and in subjects poststroke. Lower extremity texture discrimination test is easy to administer in the clinic and might suggest directions for individually tailored, lower extremity, sensory retraining protocols.

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.

Can outcome-based continuing medical education improve performance of immigrant physicians?

INTRODUCTION: Immigrant physicians are a valued resource for physician workforces in many countries. Few studies have explored the education and training needs of immigrant physicians and ways to facilitate their integration into the health care system in which they work. Using an educational program developed for immigrant civilian physicians working in military primary care clinics at the Israel Defence Force, we illustrate how an outcome-based CME program can address practicing physicians' needs for military-specific primary care education and improve patient care. METHODS: Following an extensive needs assessment, a 3-year curriculum was developed. The curriculum was delivered by a multidisciplinary educational team. Pre/post multiple-choice examinations, objective structured clinical examinations (OSCE), and end-of-program evaluations were administered for curriculum evaluation. To evaluate change in learners' performance, data from the 2003 (before-program) and 2006 (after-program) work-based assessments were retrieved retrospectively. Change in the performance of program participants was compared with that of immigrant physicians who did not participate in the program. RESULTS: Out of 28 learners, 23 (82%) completed the program. Learners did significantly better in the annual post-tests compared with the pretests (p <.01) and improved their OSCE scores (p <.001). Most program graduates (90%) rated overall satisfaction as very good or excellent. In comparison with nonparticipants, program graduates performed better on work-based assessments (Cohen's d =.63). DISCUSSION: Our intensive, outcome-based, longitudinal CME program has yielded encouraging results. Other medical educators, facing the challenge of integrating immigrant physicians to fit their health care system, may consider adapting our approach.

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.

Family physicians' perceptions, beliefs, and attitudes regarding information sharing with prostate cancer patients throughout the course of the disease.

OBJECTIVES: This study aimed to describe family physicians' perceptions regarding the concerns of men with prostate cancer as well as their beliefs and attitudes toward information sharing and decision making with prostate cancer patients throughout the course of their disease. MATERIALS AND METHODS: A questionnaire (44 items) was mailed to 780 board-certified family physicians registered in the 2003 computerized database of Clalit Health Services, Israel's largest health maintenance organization. RESULTS: Three hundred eighty-two (50%) physicians completed the questionnaires. Overall, respondents believed that patients have substantial concerns throughout the cancer trajectory and that the most troubling issue is the fear of disease progression. There were no significant differences in the amount of information physicians were willing to share with patients throughout the course of the disease. Sixty-four percent of respondents stated that they would tailor the information to the patients' wishes and characteristics. Seventy percent felt competent at breaking bad news and 74% would discuss emotions with patients. Fifty-five percent of respondents preferred that patients be autonomous in their decision making. CONCLUSIONS: Family physicians in Israel are aware of patients' concerns and recognize the importance of sharing information with prostate cancer patients. Further studies are needed to examine the practice of these attitudes and to verify whether they are compatible with patients' expectations in the relevant cultural and ethnic context.

[Recording of risk factors and preventive pharmaceutical therapy among ischemic heart disease patients in family practice during the years 1993-1998].

The review of international literature yielded unsatisfactory performance of guidelines for secondary prevention of cardiovascular diseases. This study aimed to evaluate records of the implementation of guidelines published in 1995, for the treatment and follow-up of patients after myocardial infarction in family medicine. In a retrospective sectional cohort study we identified all the patients with previous myocardial infarction in the practices of 6 family physicians, with an overall total of 97 patients. All data was gathered from manual medical records. The quality of care was evaluated according to follow-up indicators such as performance of blood pressure measurement, LDL cholesterol tests and according to secondary prevention indicators such as: treatment with aspirin, beta blockers and statins. In the cohort of 97 patients, 20.6% had diabetes, 53.6% had hypertension and 88.7% performed blood pressure follow-up, 100% cholesterol and fasting glucose tests, and 86.6% LDL cholesterol tests. Of the eligible patients, 98% received aspirin, 81% received beta-blockers and 76.2% were treated with statins. The target LDL cholesterol was not achieved by 66.7% of the patients. During the years 1993-1998 the quality of secondary prevention in the study was better than findings reported in international publications in corresponding years. However, the treatment of hypercholesterolemia should be improved.

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.

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

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

Breaking bad news: structured training for family medicine residents.

Previous research has shown that physicians experience incompetence and difficulty in dealing with patients' feelings after they have broken bad news to them. During the past 10 years, we have implemented a longitudinal training program targeting these issues. The present article describes this training and discusses its contribution to doctors' skills at approaching distressed patients. In order to cope with breaking bad news to patients and their families, physicians should be skilled at crisis intervention and communication techniques. They should also be aware of their personal attitudes and emotional reactions when breaking bad news. Each session encompassed these areas, as well as the most prominent issues arising when breaking bad news. In a 1-5 Likert scale, the course received an overall score of 4.47 (S.D. 0.51). Participants noted that they had gained relevant communication skills for future patient encounters.