Teaching internal medicine in the community.

BACKGROUND: Teaching Internal Medicine is mainly hospital-based. Chronic diseases are treated mostly in community-based ambulatory care. This study describes our experience during the first year of teaching Internal Medicine in the community, with a focus on chronic disease management. METHODS: This was an observational study describing the content of clinical exposure and the feedback from students after a two-week clerkship in community health centers. RESULTS: Over a period of three months, 54 students spent two weeks in health centers singly or in pairs. The disciplines covered were: Endocrinology, Gastroenterology, Pulmonology, Rheumatology and Geriatrics. In their feedback, the students most frequently noted knowledge acquired in the management of diabetes, infectious diseases and cardiology. The teaching content was determined by the case-mix of patients. The spectrum of conditions was wide. Students who were used to more structured hospital-based study found it difficult to cope with this mode of learning by discovery. DISCUSSION: Future research should concentrate on the transition between the different modes of learning as students move from the hospital to the community setting.

Thirty years of family medicine publications in Israel (1975-2004): what, where, and how much?

BACKGROUND: Departments of family medicine in Israel were established in the 1970s. Until now, little or no effort has been made to characterize the productivity of Israeli board-certified family medicine physicians in publishing peer-reviewed scientific articles. METHODS: Publications were identified by 2 methods. First, a PubMed search by names of current and past faculty from all the departments of family medicine in Israel (1975-2004). Secondly, all of the departments in Israel forwarded a list of all publications by their faculty (including those that do not appear in Medline). The abstracts of all publications were extracted and were separately and blindly evaluated by 2 reviewers. Publications were classified according to Medline citation, language, journal impact factor, and publication type. RESULTS: A total of 1165 publications were identified and analyzed. More than half of the articles were published in the last 10 years. Seventy-two percent were cited in Medline. Publications in English encompassed 64.7% of the publications, Hebrew 34.6%, and 0.7% other. Approximately 6% of the articles were published in journals with impact factor > or =3, with research articles accounting for 46.9%. The publication output of family medicine in Israel averaged 85.4 publications per 1000 family medicine physicians per year. Almost 70% of the articles were published in non-family medicine journals. Academically affiliated, board-certified family medicine physicians published at higher rates, averaging 334.3 per 1000 academic family medicine physicians per year (data available for 2000-2004 only). CONCLUSIONS: Publishing and research are important to the development of family medicine as an academic profession, in which Israeli family physicians show significant productivity.

[Knowledge and attitudes among women in the Arab village regarding contraception and family planning and the reasons for having numerous children].

BACKGROUND: Families with numerous children (5 or more) are a common phenomenon in the Arab sector in Israel. Whereas the fertility rate of Jewish women is 2.6, Muslim women have a rate of 4.6. Research has found that approximately half of the children were the result of unplanned pregnancies. Among the risk factors for unplanned pregnancies are: low income, the woman's level of education and marriage at a young age. In Israel a number of studies have been conducted on the use of contraception, in general, and on the status of women in the Arab population. However, to the best of our knowledge, there has not yet been a study in which Arab women have been asked how they customarily act on the subjects of family planning and contraception and what their attitudes are vis-à-vis having numerous children. OBJECTIVES: The aim of this study was to examine to what extent family planning and use of contraception exist in the Arab population and to determine the reasons for having so many children. The reasons examined included: the couple's wishes, religious faith, knowledge concerning contraception, socio-economic status and education. METHODS: A detailed questionnaire was prepared, which included socio-demographic details and questions of knowledge and attitudes pertaining to family planning and contraception and the reasons for having numerous children. The questionnaire was completed by the clinic staff, who interviewed all the women, ages 20-45, who had 5 or more children. RESULTS: Three hundred and three Arab women were interviewed, out of a total of 391 who had 5 children or more (compliance rate of 77.5%). Sixty percent of these women were married before the age of 18 and most of them are housewives (96.4%). A total of 18.8% of the women had an education of 0-4 years, 66.5% had an education of 5-8 years and 14.8% received 9 or more years of education. Most of them (92%) claimed that the decision regarding the number of children was jointly made with their husband; 24.8% thought that breastfeeding prevents pregnancy, about half of them became pregnant while breastfeeding. As to contraceptives--6.9% are currently taking contraceptive pills; 60.8% use IUD; and 11.2% had tubal ligation, most of them during a Caesarian section. In a single-variable analysis, a significant correlation was found between the women with a low level of education and more than 7 children. As the educational level rises there are fewer children in the family (P < 0.001). A significant correlation was also found between the low education of the husband and a number of children greater than 7 (P < 0.004). It was found that there is a significant high rate of women with 6 or more children that had tubal ligation. In a multi-variable analysis of the logistic regression, it was found that independent variables that predict a number of children higher than 7 are tubal ligation and the woman's level of education. The probability of uneducated women having 7 or more children is 15.2 times greater than for women with high education. Similarly, the probability that women who underwent tubal ligation have 7 or more children is 5.8 times greater than women who used no contraception. CONCLUSIONS: This study reinforces findings from previous studies that indicate the connection between the parents' education, particularly the wife's education, and the number of children. Similarly, in the rural Arab sector in Israel, the woman's education is the most significant variable determining the number of children. Moreover, we have seen that only when the number of children is particularly high and the woman's age is high, she is persuaded to have tubal ligation, as opposed to other means of contraception. These results reinforce the approach, according to which there is great importance to the fact that women in the Arab sector should obtain a high school education and more, so as to be able to properly plan the size of their family.

[The frequency and causes of resistant hypertension in primary care practices in the community as compared to those in the district advisory clinic for hypertension].

UNLABELLED: Resistant hypertension is defined as blood pressure that does not drop below 140 mmHg systolic and/or above 90 mmHg diastolic, despite treatment with three drugs in suitable combination and recommended dosage, when one of the drugs is from the diuretic group. The prevalence of resistant hypertension, which has been examined in relatively few studies, ranges between less than 3% and up to 29%. The frequency of these causes has not yet been examined in Israel. The aim of this study is to examine the frequency of patients with resistant hypertension and to compare the frequency of the different causes for this condition in the primary community clinics with those found in the district advisory clinic for hypertension. The medical files of all of the patients above the age of 20, in five rural primary care clinics in the northern district and in the Advisory Clinic for Hypertension, were reviewed to find those patients meeting the criteria of resistant hypertension. The patients that were located and met the inclusion criteria filled out a questionnaire which included demographic characteristics, drug treatment updated to their last visit, and evaluation of the various possible causes for the condition. RESULTS: Resistant hypertension was found in 10 out of 227 hypertensive patients treated in primary clinics (4.4%) and in 21 out of 131 hypertensive patients treated in the Advisory Clinic for Hypertension (16%). For 8 of the patients (25.8%) there was a single cause for resistant hypertension. For 14 patients (45.2%) there were 2-3 causes and for 9 patients (29%) there were 4 or more causes. Low treatment compliance was found in 7 patients, faulty measuring technique in 3 patients and taking drugs that raise blood pressure was found in one patient. Among the accompanying clinical conditions, uncontrolled dyslipidemia was found in 15 patients (48.4%), uncontrolled diabetes in 11 patients (35.5%) and obesity in 10 patients (32.3%). Increased sympathetic activity was found in 6 patients (19.4%) and secondary causes were found in 4 patients (12.9%). CONCLUSIONS: The frequency of resistant hypertension in primary clinics--4.4%, and in the Advisory Clinic for Hypertension--16%, as was found in our study, is identical to that described in the literature and derives from the different nature of the patients treated in each of them. The fact that in half of the patients 2-3 causes were found for resistant hypertension, and in a third of them there were 4 or more causes, emphasizes both the complexity of the medical problems of this patient group and the need for a comprehensive multi-systematic treatment approach.

Second-hand prostatism: effects of prostatic symptoms on spouses' quality of life, daily routines and family relationships.

OBJECTIVES: The aim of this study was to explore the impact of male prostatic symptoms on their partners' quality of life, daily routines and family relationships. METHODS: A structured telephone interview study was carried out on a random sample of 215 of the wives and partners of men aged 50 years or older drawn from those registered at four family medicine centres in Israel. They were asked about sleep disturbances, number of night-time wakings, and the effect on sexual relations, travel, entertainment, family and social relationships. RESULTS: The vast majority of women (86%) were affected by their partners' prostatism, with multiple consequences for their daily routines, quality of life and relationships. Sleep was the area of greatest concern, with 46% of women regularly waking due to their partners' urination disorder. The women reported other limitations: 37% noted problems with sexual functioning; 17% were unable to take long trips with partners; 10% could not visit places without toilets; while 8% were unable to go to the cinema or theatre. Women felt that their partners' prostatic symptoms were also to be blamed for upsetting family relationships (10%) and relationships with friends (16%). There was near total correspondence between women and their male partners regarding the effects of prostatic symptoms. CONCLUSIONS: Prostatism has an impact on men and women; strategies that consider the whole couple should be developed and utilized when considering treatment options.

The 'difficult patient' as perceived by family physicians.

OBJECTIVES: The aim of this study is to understand in depth the experience of the family physician faced with the patient that he perceives as 'difficult'. This was done by means of the 'long interview' as a method of qualitative research. METHOD: We interviewed 15 randomly selected Board-certified family physicians, with five or more years experience as specialists, employed in the northern district of the 'Clalit Health Services', the major sick fund in Israel. RESULTS: The participants stated that the 'difficult' patients are not those with difficult medical problems but rather those who are violent, demanding, aggressive, rude and who seek secondary gain. Patients with multiple non-specific complaints and those with psychosomatic problems are also difficult for the family physician. Appropriate use of patient-doctor communication skills and an effort to improve relations with the patient through empathy, tolerance and non-judgmental listening were suggested by the physicians as ways of making the difficult encounter easier. CONCLUSIONS: Family physicians acknowledge their responsibility for the 'difficult' patient, and seek innovative and creative ways to cope with the difficult medical encounter. The more experienced the doctor is, the less he perceives patients as 'difficult', as he learns to accept greater diversity of behaviours in his patients.

How Israeli primary care physicians perceive their role in the health care system.

In some Western European countries, primary care physicians (PCPs) play a major role in the health care system, but in Israel the health care system is in the process of being reformed and the role of PCPs has not yet been established. The purpose of the study described in this article was to determine the attitude of PCPs toward the role that they should play in the health care system in Israel and the formal training they need to fill this role. PCPs cited 12 primary functions that they should carry out, including coordinating patient care and counseling patients. Also, 60% of PCPs have undergone specialty training, and 94% think that this training is essential. Among the conclusions of the study are that a higher percentage of PCPs should undergo specialty training in order to enhance their professional status and that continued medical education should emphasize specific issues, such as the consideration of economic factors in patient management decisions, responsibility for patients' administrative issues, 24-hour responsibility for patients, and house calls.

Gatekeeping: a challenge in the management of primary care physicians.

Assesses the degree of self-reported implementation of gatekeeping in clinical practice, and gains insight into primary care physicians' attitudes toward gatekeeping and their perceptions of necessary conditions for implementation of gatekeeping in daily practice. A self-administered questionnaire was mailed to a national sample of 800 primary care physicians in Israel, with a response rate of 86 per cent. Multivariate analysis indicated that sick fund affiliation was the main predictor of self-reported implementation of gatekeeping, while specialty training predicted primary care physicians' attitude toward this role. Close communication with specialists, continuous medical education, and management support of physician decisions were identified by respondents as being important conditions for gatekeeping. Discusses strategies to gain the cooperation of primary care physicians, which is necessary for implementing an effective gatekeeping system.

Lower urinary tract symptoms in primary care--a multicenter community-based study in Israel.

BACKGROUND: Lower urinary tract symptoms are highly prevalent in older men, have been shown to affect men's quality of life, and may be associated with more serious outcomes. OBJECTIVES: To determine the prevalence of LUTS among men aged 50 years or older registered at family practice centers in Israel and to assess the effect of these complaints on different aspects of their life. METHODS: In a random sample cohort of men aged 50 years and older, fluent in Hebrew, drawn from those registered in four family clinics in Israel, patients identified with LUTS were interviewed by phone using a structured questionnaire. RESULTS: The prevalence of LUTS in our study was 21%. Less than a third of these patients had low severity LUTS (28%), 59% were rated moderate, and 13% had severe symptoms. Age had a positive correlation with the severity of LUTS, and increasing severity of symptoms had a negative effect on the daily function and quality of life of patients. CONCLUSIONS: Our community-based study shows that LUTS is a common finding among men above the age of 50 (21%) and has a significant negative effect on their quality of life and daily function. Knowledge of these data should make primary care physicians more aware of this common problem and thus improve the treatment and quality of life of these patients by better identification and prompt treatment.

Family physicians' initiative to increase compliance with screening mammography--an innovative community project.

BACKGROUND: Breast cancer is the most common malignancy among women in Israel and throughout the world. Israeli women aged 50-75 years are advised to undergo a mammographic screening examination every 2 years. However, the lack of a structured referral system is reflected in the low utilization rate of mammography. OBJECTIVES: To describe an innovative program in which family physicians in an urban clinic developed a model framework for referrals, coordinated with radiologists and surgeons, aimed at increasing compliance among women referred for mammography. METHODS: A community-based study was conducted, outside of the regular reception hours, in a neighborhood practice with a population of 527 women aged 50-75. A referral system under the supervision of family physicians was designed, and the women received appointments for mammography at specified days and hours. The results of the examination were sent to the physician who used dedicated time to continue the diagnostic and/or therapeutic process, as appropriate. At the physician's instructions a research assistant contacted the women who did not keep their appointments, and scheduled a second appointment. RESULTS: In 1993, the year prior to the study, when women referred themselves for mammography, the utilization rate was 9%. During the study year the utilization rate was 77%. Women born in Europe or America had higher compliance rates than women born in Asia or Africa (81% vs. 72%, respectively). Married women were more compliant than unmarried women (81% vs. 70%, respectively). No correlation was found between compliance and age, family history of cancer in general, or breast cancer in particular. Six new cases of breast cancer were detected. CONCLUSIONS: The initiative of family physicians increased the utilization of mammography among women under their care. Family physicians allocated time outside of their regular reception hours for the program. A relatively large number of new malignancies were found, but this impression should be confirmed or negated by a large-scale study using the same methods.

Primary care physicians in Israel: self-perception of their role in the healthcare system and policy makers' and patients' perception of them as gatekeepers.

BACKGROUND: The rapidly increasing costs of healthcare pose a major challenge to many governments, particularly in developed countries. Health policy makers in some Western European countries have adopted the policy of a strong primary healthcare system, partly due to their recognition of the value of primary care medicine as a means to restrain costs while maintaining the quality and equity of healthcare services. In these countries there is a growing comprehension that the role of the family physician should be central, with responsibility for assessing the overall health needs of the individual, for coordination of medical care and, as the primary caregiver, for most of the individual's medical problems in the framework of the family and the community. OBJECTIVES: To describe primary care physicians in Israel from their own perception, health policy makers' opinion on the role PCPs should play, and patients' view on their role as gatekeepers. METHODS: The study was based on three research tools: a) a questionnaire mailed to a representative sample of all PCPs employed by the four sick funds in Israel in 1997, b) in-depth semi-structured interviews with key professionals and policy makers in the healthcare system, and c) a national telephone survey of a random representative sample of patients conducted in 1997. RESULTS: PCPs were asked to rank the importance of 12 primary functions. A total of 95% considered coordination of all patient care to be a very important function, but only 43% thought that weighing economic considerations in patient management is important, and 30.6% thought that 24 hour responsibility for patients is important. Also, 60% of PCPs have undergone specialty training and 94% thought that this training is essential. With regard to the policy makers, most preferred highly trained PCPs (board-certified family physicians, pediatricians and internists) and believed they should play a central role in the healthcare system, acting as coordinators, highly accessible and able to weigh cost considerations. Yet, half opposed a full gatekeeper model. They also felt that the general population has lost faith in PCPs, and that most have a low status and do not have adequate training. Regarding the patients' viewpoint, 40% preferred that the PCP function as their "personal physician" coordinating all aspects of their care and fully in charge of their referrals; 30% preferred self-referral to sub-specialists, and 19% preferred their PCP to coordinate their care but wanted to be able to refer themselves to specialists. CONCLUSIONS: In order to maintain high quality primary care, it is important that all PCPs have board certification. In addition, PCP training systems should emphasize preventive medicine, health promotion, health economy, and cost-effectiveness issues. Efforts should be made to render PCPs a central role in the healthcare system by gradually implementing the elements of the gatekeeper model through incentives rather than regulations.

[What do primary care physicians think of Israel's health policy reform?].

Opinions of the National Health Insurance (NHI) Law held by primary care physicians were surveyed. A questionnaire was submitted (April-July 1997) to 930 primary care physicians employed by sick funds, including general practitioners, family physicians, pediatricians and internists. Response rate was 86%. They supported the main components of the NHI law. It was considered desirable "to a great" or "very great extent" to allocate funds to sick funds based on age and number of members (76%), to require them to accept all applicants (72%), to designate a uniform basket of services (65%), to allow members to transfer freely between funds (63%), and to allow sick funds to sell supplemental insurance (59%). However, only 41% were satisfied with the implementation of the law. Multivariate analysis showed that employment by Maccabi, Meuhedet, or Leumit sick funds had an independent effect on low satisfaction with the law as implemented, and on negative opinions about the uniform basket of services, the accepting of all applicants, and allocation of funding based on age and number of members. Those employed by the Maccabi and Meuhedet funds were in favor of allowing sick funds to sell supplemental insurance. The findings of the study have implications for policy-makers interested in increasing support for national health reform by physicians. It is important to examine possibilities of developing direct channels of communication between national policy-makers and physicians, as well as institutionalizing mechanisms that involve physicians directly in formulation of national policy.

[Physicians' opinions about the patient rights law--a qualitative study].

A qualitative analysis of the question "what is your general opinion of the Patient Rights Law?" showed that most physicians think it a good law that contributes to improved relations with patients. Physicians surveyed raised several issues relating to implementation of the law: conditions, time required to implement it and problems with language and comprehension. Fears were expressed about possible abuse of the law by patients and their lawyers, which could put medicine on the defensive. Nevertheless, most physicians think the law positive, that it has not negatively affected their work, and contributes to improved relationships with patients. They recommend that working conditions be improved in order to fully implement the law.

[Carbamazepine hypersensitivity symptoms].

Carbamazepine (C) can cause a characteristic hypersensitivity reaction (CHS¿. This multisystem reaction typically presents as fever, mucocutaneous eruption and lymphadenopathy. The syndrome usually develops between 1 week and 3 months after starting therapy, with involvement of the liver, lung, kidney and inappropriate secretion of ADH. The incidence is less than 0.001% in those treated with C and it is diagnosed clinically. With onset of CHS, the drug must be stopped and if there is no improvement, cortico-steroids should be started. When the diagnosis is in doubt, the patch test, lymphocyte transformation test, macrophage migration inhibitor factor, and other tests can be helpful. The pathogenesis is not known. Similar syndromes have been described with phenytoin and phenobarbital. There is clinical and in-vitro evidence of cross reactions between C and phenytoin. It is not known whether the CHS syndrome should be considered a premalignant state, with increased risk for the development of malignant lymphoma.

Who needs a gatekeeper? Patients' views of the role of the primary care physician.

BACKGROUND: The primary care physician serving as a 'gatekeeper' can make judicious decisions about the appropriate use of medical services, and thereby contribute to containing costs while improving the quality of care. However, in Israel, sick funds competing for members have not adopted this model for fear of endangering their competitive stance. The purpose of this study was to examine, for the first time, the stated preferences and actual behaviour of a national sample of members of the four Israeli sick funds regarding self-referral to specialists, and to identify the characteristics of patients who prefer the gatekeeper model. METHODS: Data were derived from a national telephone survey carried out in 1997. A random representative sample of 1084 of all adult sick fund members were interviewed, with a response rate of 81%. Bivariate analysis was conducted using over all chi-square tests, and multivariate analysis was performed using logistic regression models. RESULTS: A third of all respondents prefer self-referral to a specialist, 40% prefer their family physician to act as gatekeeper and 19% prefer the physician to co-ordinate care but to refer themselves to a specialist. Independent variables predicting preference for the gatekeeper model are: living in the periphery, sick fund membership, low level of education, being male, fair or poor health status, having a permanent family physician and being satisfied with the professional level of the family physician. A significant correlation was found between practising self-referral and preference for self-referral. CONCLUSIONS.: The findings indicate the importance of surveying patients' attitudes as an input in policy formulation. The study identified specific population groups which prefer the gatekeeper model, and explored the advantages of a flexible model of gatekeeping.

The role of the primary care physician in the Israeli health care system as a 'gatekeeper'--the viewpoint of health care policy makers.

The aim of the study was to determine the attitudes of policy makers in the health care system in Israel to a change in the role of primary care physicians (PCP) and to ascertain the conditions under which they would be ready to adopt the model of PCP as gatekeeper. The study design was qualitative, with analyses of in-depth structured interviews of 20 policy makers from the Ministry of Health, the Sick Funds' central administrations and the Israel Medical Association (IMA) central office. The majority of the respondents claim that they want highly trained PCPs (family physicians, pediatricians and internals) to play a central role in the health care system. They should be co-ordinators, highly accessible and should be able to weigh cost considerations. However, only about half of the respondents support a full gatekeeper model and most of them think that the gatekeeper concept has a negative connotation. They also feel that it would be difficult to implement regulations regarding primary care. The barriers to implementation of the gatekeeper model, as cited by the respondents include loss of faith in PCPs by the general population, dearth of PCPs with adequate training, low stature, lack of availability on a 24-h basis, resistance by specialists, strong competition between the sick funds including promises of direct access to specialists, the medical care habits of the general population many of whom do not settle for only one opinion, and a declared anti-gatekeeper policy by one of the sick funds. Ways to overcome these obstacles include implementation of fundholding clinics, patient education on the importance of having a personal physician, appropriate marketing by family medicine and primary care advocates, and continued training in primary care. Israeli health care policy makers have an ambivalent attitude to strengthening the role of primary care. In theory, they profess support for placing primary care physicians in a central role in the health care system. However, in practice almost half oppose the full gatekeeper model. Therefore, introduction of a gatekeeper model into the Israeli health care system should be implemented gradually, based on incentives rather than regulations. Furthermore, the idea should be marketed by the primary care physicians' professional organizations, the Ministry of Health and the sick funds to physicians as well as to patients, in order to garner their support. In light of the broad consensus that competent primary care physicians are the basis for implementation of the gatekeeper model, board certification should be gradually required by employers of primary care physicians. The process of training physicians currently working in the system should be encouraged and supported by the Ministry of Health. Given the existing opposition of policy makers to giving primary care physicians exclusive referral rights to specialists, the current policy of direct access to a limited number of specialties should be continued but not extended to other specialties.

A case report: treatment of severe anorexia nervosa with home total parenteral hyperalimentation.

UNLABELLED: In its chronic and severe phase, anorexia nervosa (AN) carries a high morbidity and mortality rate. In the severe stage, parenteral alimentation is often required. To date, the optimal regime for parenteral refeeding has not been well documented. Most, if not all, such treatment is performed on an inpatient basis. METHOD: We report here a case of an AN patient treated at home with total parenteral hyperalimentation which is, to the best of our knowledge, the first to be carried out in Israel. RESULTS: The patient has regained 10 kg during treatment, and has maintained her weight a year after treatment. Her gastrointestinal symptoms improved, and she has reduced the amount of laxatives she ingests. DISCUSSION: In this paper we will discuss the various issues and criteria applicable to this treatment, as well as the importance of collaboration between a primary care and specialized clinic.