The attitudes and knowledge of family physicians regarding malnutrition in the elderly: a call for action.

BACKGROUND: Malnutrition in the elderly places a significant burden on healthcare, social, and aged-care systems, yet it often remains undiagnosed and untreated. This study aims to evaluate family physicians' knowledge and attitudes towards the diagnosis and treatment of malnutrition in the elderly. METHODS: Based on a literature review, an online questionnaire was developed, comprised of seven knowledge-related items and eight attitude-related questions regarding malnutrition in elderly populations. We also assessed the feasibility of including two malnutrition screening questions in regular clinic visits for individuals aged ≥ 70 years. RESULTS: Surveys were completed by 126 physicians (35% response rate), mean age 47.2 ± 12.6 years; 15.6 ± 12.5 years of practice; 67% females; and 92% board-certified family physicians. Moreover, 77.6% agreed that diagnosing malnutrition is important in patients with decreased appetite. Most respondents demonstrated knowledge of nutritional screening principles (63.5%) and recognized that even obese elderly individuals could be malnourished (83.2%). There was partial agreement (60%) that normal BMI values in the elderly differ from those in younger populations. Almost complete agreement was seen for incorporating two nutritional status questions in medical visits (91%), with physicians expressing willingness to receive training in malnutrition identification and screening tools. Despite challenges such as time constraints and limited knowledge, participants were open to conducting biannual malnutrition risk screening for elderly patients. CONCLUSION: We recommend malnutrition screening in primary care followed by malnutrition diagnosis and referral of malnourished patients to the proper intervention.

Balint groups: an effective tool for improving health professionals' perceived well-being.

BACKGROUND: Physician burnout is a common problem that negatively impacts their well-being and patient care. Balint groups (BGs) deal with doctor-patient relationships. Previous studies that have demonstrated the positive effects of BGs are descriptive and based on small sample sizes. This study aims to evaluate the perceptions of health professionals who participated in BGs, determine the impact of BGs on their personal and professional well-being, and identify the factors related to these positive outcomes. METHODS: On January and February 2023 the authors have distributed a questionnaire to 142 healthcare providers in a conference and internet networks. Most respondents were family physicians. RESULTS: Participation in BGs is seen to have a positive impact on healthcare professionals' perceived well-being and professional development. Respondents who had participated in the BG reported a reduction in burnout, increased empathy, and enhanced professional identity and relationships with patients and colleagues. The study also highlighted the importance of duration of participation in BG, with attendance longer than 5 years linked to significantly more positive outcomes compared to less than 1 year. In a logistic regression analysis two factors were significantly associated with self-reported well-being: attending BGs for more than five years and perceiving BGs as a means of relieving burnout. CONCLUSIONS: The findings suggest that medical organizations should encourage the regular availability of BGs to support physicians' well-being.

Design of a bi-directional methodology for automated assessment of compliance to continuous application of clinical guidelines, and its evaluation in the type 2 diabetes domain.

We introduce a new approach for automated guideline-based-care quality assessment, the bidirectional knowledge-based assessment of compliance (BiKBAC) method, and the DiscovErr system, which implements it. Our methodology compares the guideline's Asbru-based formal representation, including its intentions, with the longitudinal medical record, using a top-down and bottom-up approach. Partial matches are resolved using fuzzy temporal logic. The system was evaluated in the type 2 Diabetes management domain, comparing it to three expert clinicians, including two diabetes experts. The system and the experts commented on the management of 10 patients, randomly selected from 2,000 diabetes patients. On average, each record spanned 5.23 years; the data included 1,584 medical transactions. The system provided 279 comments. The experts made 181 different unique comments. The completeness (recall) of the system was 91% when the gold standard was comments made by at least two of the three experts, and 98%, compared to comments made by all three experts. The experts also assessed all of the 114 medication-therapy-related comments, and a random 35% of the 165 tests-and-monitoring-related comments. The system's correctness (precision) was 81%, compared to comments judged as correct by both diabetes experts, and 91%, compared to comments judged as correct by one diabetes expert and at least as partially correct by the other. 89% of the comments were judged as important by both diabetes experts, 8% were judged as important by one expert, and 3% were judged as less important by both experts. Adding the validated system comments to the experts' comments, the completeness scores of the experts were 75%, 60%, and 55%; the expert correctness scores were respectively 99%, 91%, and 88%. Thus, the system could be ranked first in completeness and second in correctness. We conclude that systems such as DiscovErr can effectively assess the quality of continuous guideline-based care.

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.

Breastfeeding mothers' experiences with community physicians in Israel: a qualitative study.

BACKGROUND: The guidelines of all leading professional organizations recommend providing adequate support and education regarding breastfeeding; yet many mothers feel that they receive inadequate information from their health care providers in the primary care setting. This is in line with studies that demonstrate that physicians' knowledge about breastfeeding is lacking. The aim of this study was to expand our understanding of the breastfeeding-related experiences of mothers with primary care physicians (PCPs). METHODS: In this qualitative study, we interviewed breastfeeding mothers in Israel in the first six months after delivery. The interviews were conducted between December 2020 and May 2021. We used thematic analysis to explore women's attitudes and experiences with their PCPs regarding breastfeeding concerns. All authors read the transcribed interviews and independently marked statements regarding breastfeeding. Then, in a joint process, codes, subthemes and themes were defined. Each subtheme was backed up with a quote from the interviews. RESULTS: We interviewed 13 women aged 24 to 37. We identified four main themes. The first of these was physicians' inconsistent attitudes toward breastfeeding. Some were indifferent, while others related to breastfeeding solely in the context of infant development. Some were supportive, while others opposed breastfeeding. Several women revealed physicians' inappropriate and disturbing attitudes to breastfeeding. The second theme was physicians' lack of knowledge regarding medical treatment for breastfeeding issues. This theme included lack of knowledge, incorrect treatment of breastfeeding problems, and contradictions among HCPs. The third was mothers' preference for alternative resources, including individualized breastfeeding counselling, maternity and childcare nurses, mothers' groups (in person or online), and family and friends over medical treatment for breastfeeding problems. The fourth theme involved mothers' suggestions for PCPs, which highlighted the importance of communication, prenatal physician-initiated dialogue on breastfeeding, expanding professional knowledge on breastfeeding, and increasing the availability of treatment for breastfeeding problems. CONCLUSION: The women in this study reported unsatisfactory breastfeeding support by PCPs and incorrect or inadequate treatment of medical problems related to breastfeeding. They also felt they had no medical experts to approach with breastfeeding-related problems. We believe that physicians should expand their knowledge on breastfeeding medicine so that they can provide comprehensive patient-centered treatment to both mothers and infants. Education programs for improving knowledge and skills in breastfeeding issues should be implemented throughout the medical training.

Elderly Caregivers' Awareness of Caregiving Health Risks.

The aim of this study was to assess the level of awareness of elderly primary caregivers of being at physical and mental health risk due to their caregiving role, as well as to examine the impact of sociodemographic characteristics, patient care characteristics, and situational variables on caregivers' awareness. Data were collected by interview of a sample of primary caregivers aged 60+. A total of 202 primary caregivers responded positively, representing a response rate of 65% (202/311). We found a low−moderate level of awareness. The final multivariate regression analysis (F (12, 179) = 21.26, p < 0.000) revealed six variables, out of nearly 30, that are associated with a high percentage (59%) of the variability of caregivers' awareness, namely caregiving burden, caregivers' self-rated health, patient's disease severity, caregiver gender, number of children, and familial relation to the patient. Action may be taken to raise caregivers' awareness. Such interventions would possibly contribute to the quality of life and health of caregivers, enable the optimal treatment of the patient, and reduce the costs imposed on the health system and society in general.

Care for caregivers- a mission for primary care.

BACKGROUND: The number of elderly people living in the community who are limited in daily activities is increasing worldwide. This generates prolonged care, which usually falls on one family member, the family caregiver. Caregivers are prone to develop psychosocial and physical symptoms. As a result, the World Health Organization (WHO) issued a clear directive to assess and support these caregivers. The main goals of this study were to assess primary care physicians' (PCP) awareness to caregivers' health risks and the extent that they recommended preventive measures to maintain the health of the caregivers. As no suitable instrument existed, a secondary goal was to develop a scale to measure physicians' awareness to caregivers' health and preventive treatment and test it's psychometric properties. METHODS: Data were collected from a convenience sample of 201 PCP interviewed with structured questionnaires. RESULTS: The participants' mean age was 48.5 ± 11.2 years and 53.5% were female. Only 48.5% were Israel medical graduates and 72% were board-certified family physicians. Nearly 34% had been primary caregivers of family members. Most physicians (83.6%) were aware of the primary caregiver's high-risk for morbidity and mortality, and recommended preventive care. On a multivariate regression, PCP's higher level of risk awareness, their country of medical school and board certification were significant for explaining recommendations for preventive care. However, being a primary caregiver for a sick family member neither contributed significantly to the physicians' awareness to caregiving risks nor to their preventive care. CONCLUSION: Although a high percentage of physicians were aware and concerned about caregivers' health, their preventive care activities were relatively passive. PCPs should take a more active and preventive role for maintaining caregivers' health.

HbA1C variability among type 2 diabetic patients: a retrospective cohort study.

BACKGROUND: Studies have found that HbA1C variability is an independent risk factor for diabetic complications in type 2 diabetic patients. This study aims to find factors contributing to higher HbA1C variability in the community. METHODS: The study was conducted in the southern district of Israel, in Clalit Health Services (CHS). The study population was type 2 diabetic individuals aged 40-70 years in 2005, with a follow-up period of 11 years, until 2015. The definition of HbA1C variability was done by the standard deviation from the average HbA1C value of the entire study period, which was calculated for each participant. The study population was divided into two groups, "variability group" with HbA1C SD > 1.2, and "comparison group" of participants with HbA1C SD ≤ 1.2. In the univariate analysis we used X2 or Fisher test for categorical variables and independent t-test for numeric continuous variables. In the multivariate analysis we used logistic regression as well as assessing for possible interactions. Statistical analysis was ascribed for p < 0.05. All the data was drawn from the computerized medical system used by all primary care physicians and nurses in CHS working in the community. RESULTS: The study population included 2866 participants, the average age was 58.6 years, 43.3% men and 56.7% women. Each participant had an average of 20.9 HbA1C measures in their computerized medical record during the 11 years of follow up. The mean HbA1C value was 7.8%. We found 632 patients (22%) with a high variability, whereas 2234 (78%) had a low variability of HbA1C. In the "variability group" there was a higher percentage of smokers, BMI ≥ 30 and a higher rate of visits to diabetic clinics compared to the "no variability" group. In the "variability group" we found a much higher use of insulin and ACE inhibitors. The highest frequency of variability was between HbA1c values of 8.1-8.5. The multivariate analysis showed that HbA1C variability was associated with insulin use (OR = 4.1, p < 0.001), with age (OR = 0.939, p < 0.001), and Ischemic heart disease (OR = 1.258, p = 0.03). BMI ≥ 30 was almost statistically significant (OR = 1.206, p = 0.063). Gender was statistically insignificant. CONCLUSIONS: In conclusion, HbA1C variability might be used as an additional marker in Diabetes Mellitus type 2, reflecting the disease complexity characteristics and the patient's lifestyle profile.

Seasonal variations in HbA1c among type 2 diabetes patients on a semi-arid climate between the years 2005-2015.

AIMS: To investigate the seasonal variations of HbA1c values in a semi-arid climate among type 2 diabetic patients throughout 11 years of care. METHODS: A retrospective cohort study of 2860 patients with 61,187 HbA1c measures. We calculated the averages of HbA1c values of all patients and sub-groups defined by age, gender, BMI, ethnicity, insulin use, smoking status and region of residence, matched to the mean temperature and diurnal range over the 30 and 60 days prior to the HbA1c test date. RESULTS: We found a sinusoidal seasonal pattern with statistically significant HbA1c levels gaps between the spring peak and the autumn trough (F = 18.4, P < 0.001). The lowest values were in October-November and the highest in March or August with a difference of 0.17-0.31% (2-4 mmol/mol). We found different relations between the mean temperature and HbA1c depending on season, gender, age, ethnicity and smoking habits. CONCLUSION: The study identified specific subgroups in which the seasonal influence is particularly marked. A possible explanation is that during hot periods people tend to change their diet and decrease their physical activity, effecting indirectly diabetic imbalance. Recognition of the seasonal variations of HbA1c levels in this geographical region could help physicians with diabetes care and HbA1c control.

Developing a Comprehensive Geriatric Genogram Assessment Tool.

BACKGROUND: The use of graphic depictions (pictorials) to represent medical conditions is an accepted method that can complement standard methodology of comprehensive geriatric assessment. OBJECTIVES: To use the clinical pathway method to develop a comprehensive geriatric genogram assessment tool (CGGAT), which could supplement the written summary letter and recommendations. METHODS: We used the critical paths method to develop a tool to facilitate implementation of the comprehensive geriatric assessment recommendations. A multidisciplinary group of clinicians used the critical pathways method to develop a CGGAT. RESULTS: We used the CGGAT to depict the physical and functional status of patients and to complement the textual historical information, family dynamics, and current patient issues. CGGAT is a simple instrument that provides a visual structure and it can facilitate the sharing of information among team members, encourage interdisciplinary dialogue, enhance understanding and adherence on the part of patients and professionals, and reduce the burden on the clinicians who conduct the initial comprehensive geriatric assessment. CONCLUSIONS: We showed the benefits and obstacles related to the adaptation of this new tool and provide recommendations for further development.

[METHODS FOR BURNOUT PREVENTION AND THEIR IMPLEMENTATION IN THE COURSE FOR FAMILY MEDICINE RESIDENTS IN BEN-GURION UNIVERSITY OF THE NEGEV].

INTRODUCTION: Professional burnout of physicians is common and culminates in the residency period. Burnout affects the doctor's health and quality of life, and it is associated with worse patient outcomes and an increase in the incidence of medical errors. The Israeli Ministry of Health recently conducted a survey on the burnout of health professionals in Israel and showed the extent of the phenomena, calling on health organizations to provide actions in order to reduce or prevent it. In the Department of Family Medicine at Ben-Gurion University of the Negev, there is a four-year course for family medicine residents in which we teach various clinical and psychosocial topics essential for the family medicine profession. As part of this course, we set up a program to prevent burnout. Four "mini-courses" were chosen and integrated into the course curriculum for family medicine residents: "Healers' art™", "meaning in medicine ", narrative medicine and reflective writing, mindfulness, meditation and relaxation techniques. In addition, the Balint groups continued to exist during the 3rd and 4th year of residence. Health institutions and organizations are committed, as part of the interventions to improve medical quality and patient safety, to detect and monitor the burnout of doctors and to offer changes in the work environment and interventions to prevent burnout. Although it is difficult to examine the long-term effects of these courses, the residents were very satisfied with the burnout prevention courses. There is a need to step up interventions and build a research and follow-up program to assess the short and long-term outcomes of these experiences on the physicians' well-being and patients' safety.

Cardiovascular Morbidity and Risk Factors in Holocaust Survivors in Israel.

OBJECTIVES: To compare the prevalence of cardiovascular diseases and risk factors in Holocaust survivors with that of Jewish immigrants from Europe and America. DESIGN: Population-based, cross-sectional study. SETTING: Clalit, a large Israeli healthcare provider. PARTICIPANTS: Holocaust survivors (n=83,971) and a comparison group of Jewish individuals born in North or South America or European countries not under Nazi occupation or who immigrated to Israel before 1939 (n=16,058) (mean age 84±7, 61% female) MEASUREMENTS: Univariate and multivariable logistic regression analyses of cardiovascular diseases and risk factors. Matching the comparison group to Holocaust Survivors on propensity scores for exposure. RESULTS: The prevalence of ischemic heart disease (38.7% vs 31.3%), congestive heart failure (10.9% vs 9.1%), past stroke (15.7% vs 13.4%), and peripheral vascular disease (9.5% vs 7.9%) was higher in Holocaust survivors (p<.001 for all comparisons). Similar results were found for cardiovascular risk factors (diabetes mellitus (14.4% vs 13.6%), hypertension (89.3% vs 86.4%), dyslipidemia (75.9% vs 74.0%) (p<.001 for all comparisons). In multivariable analysis, matched on propensity scores and controlled for confounders, odds ratios for men and women were higher for diabetes (1.23, 1.55), dyslipidemia (1.53, 1.51), hypertension (1.56 , 1.94), stroke (1.18, 1.17), and ischemic heart disease (1.18, 1,40), but not congestive heart failure (0.95, 1.02). A Positive association was noted for peripheral vascular disease in males (1.20) but not females (0.96). CONCLUSION: Prevalence of cardiovascular diseases and risk factors was higher in Holocaust survivors. These associations were stronger in women in most cases.

Inclination towards research and the pursuit of a research career among medical students: an international cohort study.

BACKGROUND: Involvement of clinicians in biomedical research is imperative for the future of healthcare. Several factors influence clinicians' inclination towards research: the medical school experience, exposure to research article reading and writing, and knowledge of research. This cohort study follows up medical students at time of graduation to explore changes in their inclination towards research and pursuing a research career compared to their inclination at time of entry into medical school. METHODS: Students from medical schools in six different countries were enrolled in their first year of school and followed-up upon graduation in their final year. Students answered the same self-administered questionnaire at both time points. Changes in inclination towards research and pursuing a research career were assessed. Factors correlated with these changes were analysed. RESULTS: Of the 777 medical students who responded to the study questionnaire at entry into medical school, 332 (42.7%) completed the follow-up survey. Among these 332 students, there was no significant increase in inclination towards research or pursuing a research career over the course of their medical schooling. Students from a United States based school, in contrast to those from schools other countries, were more likely to report having research role models to guide them (51.5% vs. 0%-26.4%) and to have published in a peer-reviewed journal (75.7% vs. 8.9%-45%). Absence of a role model was significantly associated with a decrease in inclination towards research, while an increased desire to learn more about statistics was significantly associated with an increase in inclination towards pursuing a research career. CONCLUSION: Most medical students did not experience changes in their inclination towards research or pursuing a research career over the course of their medical schooling. Factors that increased their inclination to undertaking research or pursuing a research career were availability of a good role model, and a good knowledge of both the research process and the analytical tools required.

Elevated cancer risk in Holocaust survivors residing in Israel: A retrospective cohort study.

BACKGROUND: The purpose of this study was to examine the incidence of malignant diseases among Holocaust survivors in Israel compared with European and American immigrants who did not experience the Holocaust. METHODS: Study subjects included Holocaust survivors born in European countries under Nazi occupation before 1945, who immigrated to Israel after 1945 and were alive as of the year 2000. Living survivors were identified based on recognition criteria in accordance with the Holocaust Survivor Benefits Law. The comparison group consisted of Clalit enrollees who were born before 1945 in European countries not under Nazi occupation and were alive in 2000 or were born in any European country or America, immigrated to Israel before 1939 and were alive in 2000. The incidence of malignant diseases was compared in univariate and Poisson regression models analyses, controlling for age, smoking, obesity, diabetes and place of residence. RESULTS: The study included 294,543 Holocaust survivors, and the mean age at the beginning of follow-up was 74 ± 8.7 years; 43% males. In multivariable analyses, the rate ratio (RR) values for males and females were 1.9 and 1.3 for colon cancer, 1.9 and 1.4 for lung cancer, 1.6 and 1.4 for bladder cancer and 1.2 and 1.3 for melanoma, respectively. For prostate cancer in males, the RR was 1.4, while for breast cancer in females, it was 1.2. CONCLUSIONS: The incidence of malignant diseases among Holocaust survivors residing in Israel was higher than that among non-Holocaust survivors. These associations remained statistically significant in a multivariable analysis and were stronger for males.

Receiving family physician's advice and the 'stages of change' in smoking cessation among Arab minority men in Israel.

BACKGROUND: Receiving physician advice (PA) can increase patient's willingness to quit smoking and influence the 'stages of change' in quitting. However, less is known about this association among minority groups for whom cessation is more challenging. OBJECTIVE: We examined whether receiving advice on smoking cessation from a family physician is associated with the 'stages of change' in quitting smoking-i.e. pre-contemplation, contemplation, preparation or action-among Arab minority men in Israel with high smoking prevalence. METHODS: In 2011-12, a stratified random sample of 964 Arab men current and past smokers, aged 18-64, were interviewed face-to-face. We used ordered logistic regression models to examine the association between PA and stages of quitting smoking, adjusted for socioeconomic status, health status, sociodemographics, Health Maintenance Organizations (HMO) and smoking-related variables. RESULTS: About 40% of Arab men reported ever receiving PA to quit smoking. Participants with chronic disease(s) and higher nicotine dependence were more likely to receive PA. PA was significantly associated with the stages of change, but not with actual quitting. In multivariable analysis, receiving PA was associated with a greater likelihood of being at the contemplation or preparation stages of cessation, compared to pre-contemplation; odds ratio (OR) and 95% confidence interval (CI) were 1.95 (95% CI = 1.34-2.85) and 1.14 (95% CI = 1.09-2.076), respectively. CONCLUSIONS: Receiving PA among minority men is associated with advanced motivational stages of change in quitting smoking, but not with actual smoking cessation. Culturally, sensitive interventions and involvement of other health care providers may be considered for more comprehensive smoking cessation, in addition to PA.

Out of sight, out of mind? Does terminating the physical presence of a geriatric consultant in the community clinic reduce the implementation rate for geriatric recommendations.

AIM: To assess the effect of moving the geriatric consultation from the primary care clinic to another setting, on the rate of implementation of geriatric recommendations by family physicians. METHODS: A retrospective review of the computerized medical records of elderly patients in four primary care clinics. The rate of implementation of geriatric recommendations was compared between clinics in which a geriatric consultant was physically present (control clinics) and a clinic where the consultation took place elsewhere (study clinic). In addition, the results of the present study were compared to a previous study in which the geriatric consultation was carried out in the study clinic and the family doctor was an active participant. RESULTS: 127 computerized files were reviewed in the study clinic and 133 in the control clinics. The mean age of the patients was 81.1±6.3 years and 63.1% were women. The overall implementation of geriatric recommendations by family doctors in the study clinic was 55.9%, a statistically significant decrease compared to the previous study where the rate was 73.9% (p<0.0001). In contrast, there was no change in the implementation rate in the control clinics at 65.0% in the present study and 59.9% in the previous one (p=0.205). CONCLUSIONS: Direct, person-to-person contact between the geriatric consultant and the family doctor has a beneficial effect on the implementation of geriatric recommendations. This should be considered by healthcare policy makers when planning geriatric services in the community.

Does Specializing in Family Medicine Improve the Detection and Diagnosis of Mental Health Problems?

BACKGROUND: Approximately half the patients seeking mental health (MH) treatment consult primary care practitioners (PCPs). Previous research indicates that patients often do not receive correct MH diagnoses or appropriate treatment from PCPs. The present study examines whether a specialization in family medicine compared to other or no PCP residency programs enhances physicians' ability to detect, diagnose and treat MH problems. METHODS: Face-to-face interviews with 49 physicans in eight clinics in Israel. Two case vignettes and questionnaires assess MH awareness and factors influencing treatment. RESULTS: Significantly more family practitioners (FPs) compared to others correctly diagnosed depression and anxiety vignettes were aware of patients' MH problems and prescribed psychotropic drugs. LIMITATIONS: Small sample size, indirect examination of PCPs' skills using vignettes and the absence of psychotherapy options. CONCLUSIONS: FPs are more likely than other PCPs to detect, diagnose and treat MH problems. To improve MH detection among a broad range of PCPs, an expanded MH curriculum should be encouraged. Additional MH training should be available for all PCPs.

Voluntary Departure of Family Physicians from their Workplace: A Reflective Outlook.

OBJECTIVES: The objective of this study was to highlight and assess the important topic of the voluntary departure of the physician from his/her clinic. We used the topic of the voluntary departure of a family physician from the clinic as an example. The physician's leaving challenges the personal credo regarding the continuity of care, which is a basic concept in Family Medicine, and other professions, too: Psychiatrists are also devoted to long-term doctor-patient care. Leaving a place of work is a significant life event that can be accompanied by stress and even a crisis for the doctor, patients, and staff. METHODS: In this article, we will present four stories, of four family physicians who voluntarily left their practices, written from a reflective point of view, either before or after the actual departure. The stories will be analyzed in a qualitative way, and the central themes and narratives will be defined. RESULTS: The personal departure stories revealed important personal and systemic themes that emerge from and influence the departure process. Among the themes were: practical and emotional work circumstances; leaving as a grief process; and reactions of patients, staff, and management. CONCLUSION: Qualitative analysis revealed that the voluntary departure of the family physician has complex personal and systemic implications. PRACTICAL IMPLICATIONS: The combination of Balint group discussions and written reflections can help the physician better cope with the departure and also help patients and staff deal with the separation process.