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.

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.

A qualitative study on cultural bloodletting among Ethiopian immigrants.

BACKGROUND: Bloodletting is practiced in Ethiopia. Physicians in Israel engaging in transcultural encounters with Ethiopian immigrants are generally unaware of these ethno-medical beliefs and practices. OBJECTIVE: To assess the past and present use of bloodletting among Ethiopian immigrants in Israel. METHODS: We interviewed a sample of 50 adult patients of Ethiopian origin about present and past use of bloodletting. A second consecutive sample of 10 adult patients of Ethiopian origin who often asked their doctors to perform blood tests were identified and interviewed. Data analysis was performed by "immersion-crystallization" analysis. RESULTS: More than half of the interviewed patients reported the use of bloodletting. Scars were commonly present on their upper extremities. A qualitative analysis identified the different reasons for the use of bloodletting, the technique used and its appreciated efficacy. We also found an unexpected cultural synergy between traditional bloodletting and western medical blood sampling. CONCLUSIONS: Some Ethiopian immigrants continue to perform traditional bloodletting in their new country of residency, a practice that local physicians may not be aware of. Bloodletting-type scars on the upper extremities may be common in these patients. Patients may ask for blood sampling as a culturally accepted way to perform bloodletting (synergy).

Doctor-patient discussions of alternative medicine for back pain.

OBJECTIVE: To document the frequency of conversations about alternative medicine during primary care consultations for back pain in diverse settings. DESIGN: "Exit interview" type patient survey. SETTINGS: General practices in Seattle, Washington; rural Israel; and Birmingham, England. PATIENTS: A convenience sample of 218 adults completing a doctor visit for back pain. MAIN OUTCOME MEASURES: Frequencies of doctor-patient discussions of alternative medicine. RESULTS: Alternative medicine was discussed in a minority of visits (US site 40%, Israel site 37%, UK site 14%, p < 0.05). At each site, patients initiated at least half of the discussions. Users were five to six times more likely to discuss alternative medicine with their doctor than non-users (p < 0.05 for comparison at each site). The percentage of patients who used alternative medicine but left the consultation without discussing it was similar at all sites (US site 17%, Israel site 23%, UK site 15%). CONCLUSIONS: Discussions of alternative medicine occurred in a minority of consultations for back pain although the rate varied considerably by site. Discussions were initiated primarily by patients who use it.

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.

Universal health care? The views of Negev Bedouin Arabs on health services.

BACKGROUND: This study examines health and health care attitudes, practices and utilization patterns among the Bedouin Arab minority in the south of Israel. Particular attention is given to the effects of the new National Insurance Law that provides universal coverage for the first time, and to the identification of critical issues for further research. METHODS: Focus groups, adapted to Bedouin culture, were the primary method of data collection. Twelve groups (158 participants) from throughout the Negev met for 3-7 sessions each, using specially trained local moderators and observers. Issues discussed and analyzed included experience and satisfaction with the current health system (both modern and traditional), health service availability/barriers, health care needs, influences of social change, and the National Insurance Law. RESULTS: Participants voice dissatisfaction with modern health services in the Bedouin sector and the state of health of Negev Bedouin. They place great emphasis on the connection between health and the rapid social and economic changes, which this traditionally nomadic group is undergoing. Traditional health care is felt to still exist, but its importance is waning. The National Insurance law is having a major impact on the Bedouin, particularly because it provides universal health insurance coverage where only partial coverage had been in effect. CONCLUSIONS: This study, one of the first of its kind in the Bedouin sector, showed that the focus group method, if properly modified to cultural norms, can be a valuable research tool in traditional communities and in health service research. The findings from this research can be used to direct efforts to improve health policy and health services for this group, as well as preparing the way for further qualitative or quantitative studies.

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.

A model for educating humanistic physicians in the 21st century: the new medicine, patient, and society course at Tel Aviv University.

BACKGROUND: The impact of the social and behavioral sciences on medical education has often been limited due to a variety of organizational, curricular and professional barriers. The new "Medicine, Patient, and Society (MPS)" program in Tel Aviv attempts to rectify this educational shortcoming by exploring new ways to help students acquire the knowledge, attitudes and skills needed for becoming humanistic physicians and for helping patients (and themselves) adopt healthy behaviors. To work toward this goal, this program integrates the biomedical and psychosocial aspects of health care, providing developmentally appropriate learning experiences according to levels of training, together with a variety of educational methods, including learner-centered approaches. OBJECTIVES: To implement and evaluate the MPS pilot program. METHODS: The MPS program uses a "seamless" model of behavioral science education. This integrated curriculum interweaves several elements: behavioral science topics (presented through multiple approaches), clinical experiences, practical medical skills, and an independent project. During the program's first year there is a strong focus on "health" rather than "disease," with activities designed to encourage healthy behaviors, including smoking cessation, stress management, birth control, AIDS education, life cycle and preventive health services. Assessment of the pilot for first-year students included standardized questionnaires, student focus groups, participant observation of educational activities, and committee feedback. RESULTS: Students' quantitative evaluations indicated high levels of satisfaction with the MPS program, but their qualitative evaluations revealed some concerns. Participant observations and focus groups added unexpected insights. Student concerns included performance fears, difficulties with "learner-centered" education, and incompatibilities between more traditional first-year courses and the MPS program. Long-term follow-up will be needed to determine the impact of this emphasis on health during the first year. We assume it serves as a helpful foundation for students before they focus on disease and its sequelae in their later years.

Examining American family medicine in the new world order: a study of 5 practices.

BACKGROUND: In the last decade managed care has become the major form of health care delivery in the United States. Though some persons believe that managed care is the salvation of family practice, critics claim that it threatens many of the core concepts of primary care. We systematically examined 5 US family practices, to provide a microanalysis of the current situation, particularly from the viewpoint of the care providers. METHODS: During 1997 and 1998, case studies were conducted at 5 sites using long interviews, focus groups, and extensive participant-observation of provider-patient and provider-staff interactions. Participants included 54 health care providers, 18 administrators, 45 nurses or nursing assistants, and 30 ancillary staff at the sites. RESULTS: We found dominant themes of rapid change, disruption, increased demands, interference in clinical decision making, and adaptation. Health care providers have the perception of being in the midst of a revolution with disruptions of key relationships and local knowledge. The clinicians in the study feel a loss of certainty, control, and autonomy. CONCLUSIONS: There appears to be a rampant ideologic competition occurring between business and beneficence for the moral sensibilities of family medicine providers. This is potentially hazardous to feelings of trust in the provider-patient relationship. The focus of much of the warring has been on managed care, though many of today's problems either predated its development or were peripheral to it. More empirical and observational studies are needed to document the fundamental changes taking place in today's health care environment.

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.

A report from the Second International Forum for Primary Care Research on Low Back Pain. Reexamining priorities.

STUDY DESIGN: Consensus process. OBJECTIVES: Reexamining and redirecting the research agenda for low back pain in primary care. SUMMARY OF BACKGROUND DATA: Most research, publications, and funding have traditionally been directed toward specialty and biologically oriented investigations of "spinal disorders" from biomedical and biomechanical perspectives. Beginning in the mid-1980s, primary care researchers began to investigate this field in earnest, focusing on lower back pain as a pain syndrome within an individual, family, and community context. Unfortunately, more progress has been made on what should not be done in diagnosing and treating lower back pain than on what should be done. METHODS: This was a modified group process designed to reach consensus among an international group of primary care lower back pain researchers. RESULTS: Nearly all of the research priorities from the initial 1995 forum are still thought to be important, although only modest progress has been made on most of them. The priorities perceived to be the most feasible to investigate and the ones in which the greatest strides have been achieved are in methodologic rather than substantive areas. Identifying subgroups of people with lower back pain is still given top ranking in 1997, but the priorities have changed dramatically. Greater emphasis is given to finding predictors and risk factors for lower back pain chronicity, improving self-care strategies, and stimulating self-reliance. New items now make up 50% of the top 10 priorities. In general, the additions reflect a greater emphasis on expanding methodologic avenues of inquiry. CONCLUSIONS: Methodologic advances, the enlistment of new techniques and disciplines, and redirected research efforts may facilitate progress in the diagnosis and treatment of lower back pain.

[Attitudes of family physicians to alternative medicine].

80 Israeli family physicians (51.25% men and 48.75% women) participated in a telephone survey concerning attitudes, practices and experience with alternative medicine. 23.75% reported practicing 1 or more alternative techniques, most commonly acupuncture (28%) and hypnotherapy (24%). 55% had referred at least 1 patient to an alternative practitioner during the preceding month. Physicians who studied in Israel or Western countries referred more patients than graduates of medical schools of Eastern Europe. Specialists referred patients more often than residents. The most common reason for referral was back pain.

Evaluating family practice residencies: a new method for qualitative assessment.

BACKGROUND AND OBJECTIVES: This study reports on a novel qualitative method for evaluating family practice training programs. Previous evaluation techniques have generally been quantitative in nature and have limited their scope to a few isolated elements of residency education. METHODS: A guest faculty, working in conjunction with local faculty, conducted a site analysis of an East Coast and a West Coast family practice residency. Multiple qualitative techniques were used, including participant observation, focus groups, long interviews, and analysis of key texts. Program strengths and weaknesses were analyzed, and a discrepancy model was used to compare program goals and ideals to the actual training realities. The analysis used a process of immersion/crystallization, and triangulation of the multiple data sources was achieved through repeated comparisons. RESULTS: This report focuses on the process of the evaluations, rather than on their content. In general, the sites have achieved most of their objectives, but notable limitations are present at both programs. This is particularly apparent in terms of multiple demands on faculty, the lack of a shared vision, and program isolation. CONCLUSIONS: Significant lessons were learned from these initial assessments, which can be used to further refine the method. Comprehensive qualitative reviews may provide unexpected insights and identify program limitations and strengths.

An agenda for primary care research on low back pain.

In October 1995, an International Forum for Primary Care Research on Low Back Pain was held in Seattle, Washington. The Forum focused on the broad range of decisions that patients and their primary care providers make concerning how to best manage low back pain. In addition to providing a venue for summarizing the current state of knowledge about these issues, a major goal of the Forum was to draft an agenda for future primary care research on low back pain. Previous efforts to delineate priority areas for research in this field have emphasized the concerns of basic scientists, pain specialists, and surgeons while ignoring the major concerns of patients and providers in the primary care setting, where the majority of patients with back pain are seen. This article describes the group consensus process used to draft an agenda, presents the items included, and contrasts this primary care agenda with agendas for back pain research developed primarily by specialists. This agenda identifies for the first time the clinical and methodologic issues that primary care experts on back pain consider to be of highest priority. Hopefully, it will help focus future primary care research and encourage funding agencies to give priority to the issues identified.

Trials and tribulations of country doctors: a qualitative study of doctor-patient relationships in rural Israel.

Rural areas of Israel are organized into small villages that attract physicians by offering inexpensive accommodation and the promise of a high quality of life. However, conflicts often arise in the relationship between the village residents and the doctor, leading to dissatisfaction and physician turnover. In order to examine the issues, we conducted a qualitative study of rural physicians using a group interviewing technique, called focus groups. The sample consisted of 46 physicians, aged between 35 and 45, of whom 60% were male. In the focus groups, the physicians mainly discussed issues of unclear boundaries between private life and physician roles, exaggerated expectations on the part of community members, difficulties with teamwork, the impact of the physician's family, work satisfaction, and burnout. Recommendations for physicians considering rural practice include making a careful and studied choice of a village before making a final decision, setting both clear professional limits and an overall time limit for service, allowing for mistakes, and organizing Balint-type physician support groups.

[Guidelines for treating low back pain in primary care. The Israeli Low Back Pain Guideline Group].

Low back pain (LBP) is a common problem in primary care, the successful management of which poses special challenges for patients and practitioners alike. It has been estimated that all adults will suffer LBP sometime during their lifetimes. It is one of the most frequent reasons for visiting a primary care physician, yet practitioners often find it difficult and frustrating to treat. This medical protocol is concerned with the diagnosis, treatment, and follow-up of low back pain in adults. It was developed for community-based, primary care physicians (general practitioners, family physicians, and internists) to serve as a general outline, to be adjusted in accord with the individual's circumstances. The protocol provides a "Ten Commandments" for the care of LBP, outlines the background of the problem, presents an overall algorithm and deals with issues of diagnosis, imaging, and treatment. In general, LBP in primary care is conceived of as a benign ailment, and emphasis is placed on reducing pain, resuming functioning and returning to work. The main task of the physician is to distinguish the less than 10% of cases with serious, specific causes of LBP from the more than 90% with nonspecific etiologies. In the great majority of patients, imaging studies such as X-ray, CT, MRI, and bone scan, and also EEG are unnecessary.

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)

An outbreak of venomous spider bites in a citrus grove.

An outbreak of necrotizing spider bites in citrus groves in the Aravah valley of southern Israel is reported. Bites were clinically diagnosed to be due to the brown recluse spider Loxosceles rufescens (Dufour, 1820) (Loxoscelidae), one of the most common spiders identified in the groves. The distribution of L. rufescens in this area appears to be restricted to one locality, suggesting that it was a point introduction. This report suggests a previously unreported risk for workers in citrus groves and describes an ecologic intervention consisting of tree pruning and clearing of ground cover that appears to have been successful in reducing the incidence of bites.