Too Much Healthcare: The Harmful Combination of Overdiagnosis and Medical Overuse, Told and Untold Stories.

BACKGROUND: Too much healthcare is prevalent, wasteful, and harmful. It consists of two separate phenomena: overdiagnosis and overuse. Overdiagnosis is the labeling of a person with a disease or abnormal condition that would not have caused the person harm if left undiscovered. Individuals derive no clinical benefit from overdiagnosis, although they may experience physical, psychological, or financial harm. It has been found that 15-30%, 20-50%, 0-67%, and 50-90% of people with screen detected breast, prostate, lung, and thyroid cancer, respectively, are overdiagnosed. Since many screening tests have trade-off between benefit and harm, a shared decision-making approach is essential. Incidental findings are very common and may also cause overdiagnosis. Overdiagnosis is recognizable in populations and not at the individual level. However, overuse is recognizable at the level of the individual practitioner. Choosing Wisely, an intervention directed at reducing low value care, now faces the challenge of developing interventions that go beyond recommendations. While some of the drivers of overdiagnosis and overuse are similar, different and parallel strategies are needed in order to reduce them. This is one of the major challenges to our health care system.

Comparison of antidepressant use between adult populations living in urban and rural communities in Israel.

Background: Depression and anxiety are among the most prevalent disorders in primary care. City dwelling is commonly cited as a risk factor for mental disorders, but epidemiological evidence for this relationship is inconclusive. Objective: To compare the prevalence of antidepressant use, as a proxy for the level of depressive disorders, between patients in Israeli urban and rural communities. Methods: A cross-sectional study, based on data drawn from the registry of the largest health maintenance organization in Israel. The prevalence of antidepressant purchase during 2014 was evaluated for 581291 patients living in urban and rural communities. Data were also collected for potential confounding variables: age, gender, comorbidity, socioeconomic status and being a holocaust survivor. Results: Results showed higher rates of antidepressant use among patients living in urban (11.8%) compared with rural communities (8.1%; <0.001). A particularly high rate of antidepressant use was found on kibbutz (15.9%), a collective rural community in Israel, compared with both urban and other rural communities. Kibbutz compared with other rural communities: odds ratio (OR) = 1.73, P < 0.001; urban communities compared with non-kibbutz rural communities: OR = 1.21, P < 0.001. A significantly lower rate of antidepressant use was found in urban and rural Arab-majority communities (3.9% and 3.8%, respectively). Conclusions: Antidepressant use varies significantly between different communities in Israel. The highest rate of antidepressant use in our study was found on kibbutz, followed by that in urban communities, with the lowest rates in non-kibbutz rural communities. This difference may derive from different depression rates, stigma of mental illness and awareness of mental disorders.

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.

Patient's evaluations and expectations of primary care medicine in Israel revisited after two decades - Health Service Research.

BACKGROUND: The European Task Force on Patient Evaluations of General Practice's (EUROPEP) internationally-validated questionnaire measures patients' satisfaction with their primary care physicians. A study published in 1999 showed positive evaluations of primary care among patients across Europe and included 1603 Israeli patients. Major changes have taken place during the past 20 years, in Israel's society, in the healthcare system, and particularly in primary care clinics. OBJECTIVES: The study aims to reevaluate patients' satisfaction with their primary care physicians and care clinics in Israel and compares the results to the 1999 survey. METHODS: A survey based on the EUROPEP questionnaire was conducted among 1617 people. Data collection was carried out by an internet panel for the Hebrew speaking population and by a phone questionnaire for the Arabic speaking population. RESULTS: The study's results show a significant reduction in satisfaction. Notably, patients' satisfaction with physicians' support relating to emotional problems and physicians' explanations about referrals and workup plans have dramatically deteriorated. CONCLUSIONS: The decrease in patients' satisfaction with primary care physicians and clinics found in the current study is concerning and requires recognition and further exploration. PRACTICE IMPLICATIONS: The results may be used as a baseline for future assessments of trends in patients' satisfaction.

Illness in context and families as teachers: a year-long project for medical students.

The authors describe a program for second-year students in Tel Aviv University's six-year medical school. The program's aim is to teach students the importance of context and interactions in patient care by exposing them to a real patient-family-doctor interaction using narrative-based methods to encourage reflective learning. Each student meets five times a year with a volunteer family, one of whose members suffers from a chronic disease. The program endorses a "patients as teachers" approach, as families are considered to be teachers for the students and not as objects of investigation and assessment. The students receive supervision in small groups, to enhance learning and reflection. To appraise the extent to which students had obtained the required knowledge, skills, and attitudes, the authors extracted reflections regarding the learning experience from students' essays. Major themes identified were becoming "family sensitive," building and improving communication skills, questioning intrusiveness, adopting a nonpatronizing and nonjudgmental attitude, developing reflective skills, creating a future professional model, and experiencing and appreciating continuity of care. The authors argue that learning to listen to patients' narratives, developing a reflective attitude, and being sensitive to patient-family-doctor interactions are of value to all doctors, and therefore programs similar to theirs should be established as part of general medical school education and not just in the context of family medicine.