Attitudes of women with breast cancer regarding the doctor-patient relationship.

Breast cancer is the most common type of cancer among women. The current study uses the qualitative method to examine breast cancer patients' viewpoint regarding the doctor-patient communication and its implications during their treatment. All the women brought up the same central themes: Assuming an active attitude in their life. One of the ways to be active is by helping others in her situation. Dealing with uncertainty. Need for support from the surroundings. Feeling vulnerable in every area of life. The doctor should encourage the patient to adopt an active position, try to minimise their uncertainty, support relatives to become involved and address all problems and not just the medical complaint of their patient. This study is a basis for developing training programmes in the medical professions, in order to improve their communication with cancer patients.

Managing obesity: a survey of attitudes and practices among Israeli primary care physicians.

OBJECTIVES: To document and assess Israeli family physicians' (FPs) knowledge, attitudes and practices regarding the management of overweight and obesity. METHODS: Anonymous questionnaires were completed by 510 family physicians (82% compliance rate). The questionnaires were distributed in various continuous medical education sites of FPs in Israel. The measures included attitudes to and resources of knowledge on weight management, views regarding the prescription of drugs, approaches to and strategies recommended for weight loss. RESULTS: In all, 73% of FPs viewed weight management as important and reported that they often treated cases of overweight and obesity, including for patients without concomitant risk factors. The medical advice most frequently offered is: increase physical activity, decrease number of total calories (eat less) and consultation with a dietitian (95, 81 and 58% respectively). However, most responders (72%) believed that they had limited efficacy in treating obesity and considered themselves not well prepared by medical school to treat overweight patients. Some 60% reported feeling that they have insufficient knowledge regarding nutritional issues. Regarding pharmacotherapy for treating obesity, only 66% knew the drugs' prescription indications. However, the vast majority (87%) knew about the gradual increase of weight after stopping drug treatment. CONCLUSIONS: Knowledge gaps and ambivalent attitudes toward obesity management were found. More education focusing on obesity, from medical school to post-graduate learning, seems warranted based on these findings.

Depression and falls among community dwelling elderly people: a search for common risk factors.

STUDY OBJECTIVE: s: Depression and falls are two common conditions that impair the health of older people. Both are relatively underdiagnosed and undertreated problems in primary care. The study objective was to investigate whether there was a common set of risk factors that could predict an increased risk of both falls and depression. DESIGN: This was a cohort study drawn from a primary care clinic, with a one year follow up. Dependent measures included: reporting two or more falls in the past year and a score of 7 or over on the S-GDS (Short Geriatric Depression Scale). A parsimonious set of risk factors was selected that predicted both outcomes based on a series of discriminant function analyses. PARTICIPANTS AND SETTING: The setting was a primary care clinic serving a mixed socioeconomic population, in Beer Sheva, Israel. The sample included 283 General Sick Fund members, aged 60 and over, who completed both baseline assessments and one year follow up interviews. MAIN RESULTS: At the one year follow up, 12% of the sample reported frequent falls in the past year and 25.5% of the sample screened positive for depressive symptoms. A set of five risk factors that included: poor self rated health, poor cognitive status, impaired ADL, two or more clinic visits in the past month, and slow walking speed (g10 seconds over five metres) was successful at discriminating between fallers and non-fallers (86% discrimination) and between those with and without depressive symptoms (76%). For every risk factor added, there was a significant increase in the proportion of respondents who had depressive symptoms. A similar result was found for falls. CONCLUSIONS: These results show that there is a common set of risk factors that increase the risk of two common outcomes in geriatric medicine, falls and depression. For a general practitioner or a geriatric physician, it might be easier to detect these risk factors than to diagnose depression or high risk for falls. When these risk factors are detected in patients the physician can then be more active in direct probing about depression and falls.

Domestic violence: prevalence among women in a primary care center--a pilot study.

BACKGROUND: Domestic violence is a prevalent problem with serious consequences, including the risk of death. The lifetime prevalence ranges from 21 to 34%, with 8-14% of them reporting abuse in the previous year. The incidence seen in primary care practice is about 8%. Despite this high rate, domestic violence is under-diagnosed in primary care. OBJECTIVES: To estimate the prevalence of domestic violence among women visiting a primary care center, to characterize them and to evaluate a screening tool. METHODS: A brief anonymous questionnaire (in Hebrew and Russian) for self-completion was used as a screening tool. During October 1998 we distributed the questionnaires in a primary care clinic in Beer Sheva to all women aged 18-60 years whose health permitted their participation. A woman was considered at high risk for domestic violence when she gave a positive answer to at least one of the three questions related to violence. The risk factors for domestic violence were calculated by odds ratio with 95% confidence intervals. RESULTS: The response rate was 95.7%. We found 41 women (30.8%) at high risk for violence. Women preferred talking about this issue with their family physician. Women at highest risk were older than 40 years, had emigrated from the former Soviet Union during the last 10 years, were living alone, and were unemployed. None of the women visited the Domestic Violence Center during the study period and 2 months thereafter. Only three women tore off the Center's address and phone number attached to the questionnaire. CONCLUSIONS: The anonymous questionnaire was well accepted and had a high compliance rate. Its disadvantages are that respondents must be literate and that it permits the woman to continue with her "secret-keeping" behavior. A high prevalence of domestic violence among women visiting a primary care clinic should convince family physicians to be more active in diagnosing the problem accurately among their patients, providing treatment and preventing further deterioration and possible danger. Further effort should be directed at improving the clinic staff's ability to detect domestic violence among patients, and at developing management programs in the health system to help combat domestic violence.

Doctor-patient concordance and patient initiative during episodes of low back pain.

Doctor-patient concordance and patient initiative were examined in a prospective network interview study, with telephone follow-up, of a cohort of 100 patients presenting with low back pain to their family physician. The average overall rate of concordance was 60% (95% CI = 53 to 66), with the highest rates for radiographic imaging studies and sick leave. No correlation was found between concordance and patient parameters. Subjects initiated an average of two (95% CI = 1.7 to 2.3) diagnostic or therapeutic procedures, the most common of which were for medications (40%), followed by bed rest (26%) and back school (22%). One out of every six subjects initiated a referral to a complementary therapist. Positive correlation was found between patient initiatives and pain severity (P = 0.022) and disability (P = 0.02). There was a negative correlation between the subjects' initiatives and their belief that the physician understood the cause of their pain and its influence on their life (P = 0.02). Overall, those patients who described more pain or disability sought more types of diagnostic and therapeutic measures, while those who felt they had been understood sought less.

Patients' smoking status: the family practice physician's view.

BACKGROUND: Smoking rates have decreased in western countries as well as in Israel during the past 20 years. OBJECTIVES: To estimate current rates of smoking and smoking cessation, and to assess factors associated with smoking and smoking cessation in family practice. METHODS: Prospective face-to-face interviews were conducted with 1,094 subjects, aged 16 years or older, registered in a family practice. RESULTS: Of all subjects studied, 746 (68.2%) were nonsmokers, 237 (21.7%) were current smokers, and 111 (10.1%) had stopped smoking. Overall, 31.8% of the males and 13.8% of the females were current smokers, and 20.1% males and 2.4% females had stopped smoking. Current smoking and smoking cessation rates were significantly and inversely associated with age among males and females. Smoking rates were higher among males and females who were married, had 10-12 years of education, and among males of North African origin and females of Israeli origin. The number of cigarettes smoked per day was associated with smoking and smoking cessation in males, but not in females. The highest rate of quitting occurred among males who smoked > or = 25 cigarettes per day. In a multiple regression analysis, gender and the number of cigarettes smoked per day were the most significant factors that predicted smoking cessation. The most common reason for stopping was the appearance of new signs of illness or the development of a new chronic disease, followed by a physician's recommendation to quit smoking. CONCLUSIONS: Female smokers and male smokers who smoke less than 25 cigarettes per day are the least likely to quit smoking. Future programs should be designed for and targeted at these groups of patients.

[Identifying the elderly at risk for falling and accompanying protocols].

Falling is one of the main problems affecting the health of the elderly. A community project was carried out to detect elderly people at high risk for falls. One of its aims was also to develop tools allowing primary care professionals to detect the elderly at risk for falling. Such a screening test in the community-dwelling elderly (EFST) and a protocol for diagnosis and treatment of the elderly at risk for falls is presented.

Sex differentials in predictors of mortality for patients with adult-onset diabetes: a population-based follow-up study in Beer-Sheva, Israel.

OBJECTIVE: To test the hypothesis that factors predicting mortality differ between diabetic men and women. RESEARCH DESIGN AND METHODS: A total of 498 known patients with diabetes residing in a well-defined geographical area and receiving primary health care in 3 primary care community clinics were interviewed and examined between 1988 and 1990. RESULTS: By 31 July 1998, after a mean follow-up period of 7.8 years, 148 patients (68 men and 80 women) had died (29.7%). No statistical differences in survival rate or in the specific causes of death were found between men and women. In the univariate analysis of factors examined at baseline, GHb levels were significantly higher among women who died compared with women who survived, but this was not the case for men. Conversely, a trend of higher triglyceride and uric acid levels was found for men who died compared with men who survived, but this was not the case for women. Multivariate Poisson regression analysis showed significantly higher risk ratios for mortality in men > or = 63 years of age, men with microalbumin excretion > or = 30 mg/l, and men with higher triglyceride levels. In contrast, the analysis in women showed that higher GHb and creatinine levels and a reported history of heart disease were the only factors at the baseline examination significantly and independently associated with an increased risk ratio of mortality. CONCLUSIONS: The results suggest the existence of sex-specific interactions with various metabolic factors associated with diabetes that may have a different effect on mortality for each sex.

A course for teaching patient-centered medicine to family medicine residents.

In 1988 the Department of Family Medicine at Ben Gurion University of the Negev in Israel developed a course that helps residents to acquire the attitudes and skills required for practicing patient-centered medicine. In the patient-centered approach, the physician relates to patients according to their needs rather than the doctor's own agenda, moving from professional control to patient empowerment. Though there are many elements to this method, certain basic orientations and skills are essential and must be taught, modeled, and reinforced in trainees. To accomplish these aims, a three-year course was developed, which is largely based on directed reading, open discussion, case presentations, role-plays, and Balint groups. It is composed of four levels, each of which must be mastered before residents can move to the next. The levels are (1) doctor-patient communication; (2) family-systems theory-concepts; (3) family-systems theory-practical applications; and (4) multidimensional approaches to simulated patients. In this article, the authors describe the course's concepts and content, and some indicators as to its influence on graduates.

The prevalence of a history of child sexual abuse among adults visiting family practitioners in Israel.

OBJECTIVE: To determine the prevalence of a history of child sexual abuse (CSA) in a random sample of adult patients presenting for routine health care to family practice clinics in Israel. METHOD: One thousand and five randomly selected patients aged 18 to 55, attending 48 clinics, participated in this questionnaire study. RESULTS: Twenty-five percent indicated that they had been sexually abused as children. More women reported CSA (p < .0001 ) than men, as did women originating from Western countries (p = .02) and those with more than 12 years of education (p = .01). There were no significant associations between CSA and the other socio-demographic variables examined. Fondling was the most common and intercourse the least common activity experienced. Forty-five percent of the perpetrators were previously known. The mean age at which the child sexual abuse began varied between 10 and 14. Only 45% of the subjects had ever told anyone about the experience. CONCLUSIONS: Since no other prevalence study has been reported to date in Israel, these findings suggest that as in other Western countries CSA is a relatively common problem. Family physicians and other health professionals should be aware of this high prevalence and its known potential for initial and long-term deleterious outcomes.

Death foretold.

We briefly trace the history of a belief in the possibility that a person in apparent good health may accurately predict his or her own demise. The phenomenon is referred to as death foretold and we present presumed examples of it from the Bible, world literature, medical writings and newspaper reports without pretending to completeness. In two widely quoted scientific papers, death foretold is subsumed under the wider heading of decease due to psychic stress. We speculate on a possible link between the two, taking into consideration the fact that most people who prophesy their end are of an advanced age.

Advantages of the psychiatric liaison-attachment scheme in a family medicine clinic.

BACKGROUND: The study presents the advantages of the psychiatric liaison-attachment scheme, by analyzing the psychiatric consultations of a 12 months period (1995), in an urban family medicine clinic in Israel. METHOD: Family physicians filled a questionnaire about all patients who had been seen at the consultation. RESULTS: The consulting psychiatrist saw 46 patients. The reasons for consultation were mostly to confirm a diagnosis and to decide upon medications. Medical diagnoses most often made were depression and personality disorder. The psychiatrist referred 35% of patients for further therapy in the psychiatric clinic. The family physicians would have referred 45% of patients to psychiatric clinics, if they had no psychiatric consultation available. All patients referred complied with the recommended referral. Family physicians saw accessibility as the main advantage of this consultation strategy. LIMITATIONS: This study was done in a unique setting, a teaching family medicine clinic, with nine specialized family physicians working in the psychiatric liaison-attachment scheme for as long as 10 years and more. Therefore the results of this study may not be generalized to other clinics. CONCLUSIONS: We conclude that the advantages of the psychiatric liaison-consultation method were for the patients, the family physicians and the psychiatric consultant. The main advantages for the family physicians, as stated by them, were the accessibility, the non-stigmatic availability of a psychiatrist in the clinic, and the good compliance with referral to psychiatric therapy. For the consulting psychiatrist, the advantages were the valuable information from the family physicians and the social worker, the better follow-up of patients and the team work with the family practice team.

A new look at low back complaints in primary care: a RAMBAM Israeli Family Practice Research Network study.

BACKGROUND: Low back pain (LBP) is one of the most frequent reasons patients seek consultations in primary care, and it is a major cause of disability. Our research examines the natural history of LBP and the prediction of chronicity in the context of patients presenting to family medicine clinics. METHODS: We performed a prospective cohort study of new episodes of LBP within the framework of a national family practice research network. The setting was 28 primary care family practice clinics located throughout Israel. Of 238 eligible subjects, 219 (92%) completed the study. RESULTS: During the 2-month study period, 2 subjects were referred to the emergency department and discharged, and 2 others were hospitalized. Forty-five percent did not require bed rest, and 38% of the employed were not absent from work. Seventy-one percent showed improvement in functional status; however, only 37% noted complete pain relief. Clinical and demographic data usually did not predict LBP-episode outcomes. The strongest predictors of chronicity were depression, history of job change due to LBP in the past, history of back contusion, lack of social support, family delegitimization of patient's pain, dissatisfaction with first office visit, family history of LBP or other chronic pain, coping style, and unemployment. CONCLUSIONS: The cohort patients displayed a relatively benign natural history of LBP, matched by benign clinical behavior from their physicians. In Israeli primary health care, acute LBP is infrequently associated with hospitalization or prolonged work absenteeism. Although most patients have functional improvement, pain often lingers. Almost all predictors of chronicity are psychosocial.

Validation of a fall-risk screening test, the Elderly Fall Screening Test (EFST), for community-dwelling elderly.

Falls are the most common type of injury among the elderly, and the source of both functional and psychological morbidity. The aim of this study was to validate the Elderly Fall Screening Test (EFST). In a community primary-care clinic, the members 60 years or older who were functionally independent were screened. Of the 568 elderly persons who met these criteria, 361 were interviewed once and 283 persons were re-interviewed a year later. The EFST, a five-item test, was used to divide participants into low- and high-risk groups. Concurrent criterion validity was assessed by physical examinations conducted by physicians who were blind as to the risk designation. Using data from the follow-up interview, predictive validity was assessed on both fall-related and general health measures. Based on the results of the EFST, 28% of the respondents were designated as being at high risk for falls (i.e. having a score of two or more risk items). The results of physicians' examinations corroborated the screening test results in 75% of the cases, with 83% sensitivity and 69% specificity. In the follow-up interview, the high-risk group, as compared to the low-risk group, was more likely to have high scores on EFST, a fall in the past month or year, frequent near falls, and an injurious fall. Those with high EFST scores were more likely to report four or more sick days in the past six months, a hospitalization in the past year, poor self-rated health, a decline in health in the past 6 months, and symptoms of depression. The EFST has both criterion and predictive validity. It can be useful in community-based prevention programmes with functionally independent elderly people.

Responsibility taking and role definition in family practice: effect of training and practice setting.

There is evidence that family physicians (FPs) reduce health care costs by reducing patient referral to more expensive secondary and tertiary care facilities. Presumably, the effectiveness of FPs in meeting patients' needs is related to their role definition and willingness to assume responsibility. The purpose of this study was to determine the influence of training and practice setting on responsibility taking and role definition of FPs. A previously developed and validated self-administered questionnaire was completed by 153 certified FPs and FP residents from five departments of family practice in Israel. The main independent variables were previous training and practice setting. The main outcome measures were self-reported data on responsibility taking, role boundaries, and reported role performance. The results showed that certified FPs were more willing to assume responsibility, to define broader role boundaries, and to perform more specialized interventions than residents. Differences in practice setting affected only reported performance, with physicians who practice in rural clinics performing more specialized activities than those in urban clinics. Multiple regression analysis shows that professional development is associated with an increased willingness to assume responsibility; this willingness affects role boundaries definitions, which affects reported performance. Practice setting alters the tendency to perform a wider range of interventions, but does not affect physicians' attitudes.

Talking about the pain: a patient-centered study of low back pain in primary care.

Despite considerable research, low back pain (LBP) often proves resistant to treatment. This study was designed to increase the understanding of low back pain through access to patients' perceptions, beliefs, illness behaviors and lived experiences. The findings are based on focus groups, individual interviews and participant observation conducted in primary care practices and community settings in three regions in Israel. Inclusion criteria for the interviews and groups include age greater than 18 years and a history of at least one episode of LBP. Seventy-six LBP subjects between the ages of 18 and 67 (mean 39.5) participated, 65% male and 35% female. The analytic method is content analysis, consisting of a formal, multi-step process designed to elucidate inherent patterns and meanings. This research finds that LBP subjects articulate a rich world of pain sensation, awareness and meanings. From subjects' own words and experiences we present a patient-centered classification system of backache symptoms based on typical pain intensity, dysfunction, duration and treatment. An elaborate system of explanatory models of LBP and a typology of dominant coping styles designed to either minimize pain or maximize function are also derived. Subjects choose multiple conventional and alternative treatments based on 'what works', and articulate ample criticisms of and suggestions for the medical system. In addition, we find that variations in the social construction of the back pain experience vary sharply, even between similar neighboring communities. Given the difficult state of diagnosis and treatment and the frustration of practitioners, attempts at greater understanding of patients' health beliefs, experiences, and behaviors are warranted.(ABSTRACT TRUNCATED AT 250 WORDS)

Measuring patient satisfaction in primary care: a joint project of community representatives, clinic staff members and a social scientist.

We describe the process of planning and developing a questionnaire and conducting a patient satisfaction survey in a neighbourhood clinic in Beer-Sheva, Israel. The project was conducted by the clinic staff members, patient representatives and a medical sociologist. The satisfaction survey was conducted in patients' homes, with a 67% response rate. General satisfaction and satisfaction with specific components of service are described. Patient satisfaction was higher among men than among women, and negatively correlated with family size. The strongest predictor of general satisfaction was satisfaction with physicians' services. Implications of the survey results were decided upon by active collaboration between the clinic staff and the patient representatives. The inferences drawn from the patients' replies and the changes introduced as a result of them, are discussed. Health care consumers should be active participants in carrying out surveys of satisfaction on a regular basis.

[Is your patient a Holocaust survivor?].

This presentation is meant to heighten physicians' awareness of the special needs and strengths of Holocaust survivors. There has been much research on patients of psychiatric clinics, and there is considerable evidence from other sources that Holocaust survivors are a high risk group for mental, as well as other medical problems. A physician who is aware of this is better able to diagnose and treat survivor-patients. Therefore, it is proposed that questions about the Holocaust be routinely included in the taking of personal histories from patients who came from Europe after World War II. 2 examples of Holocaust survivor patients are described, to show how the use of this information can improve the care provided by the physician.