[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.

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.

Home intravenous antibiotic therapy programme, 1999.

OBJECTIVES: To evaluate the cost-effectiveness and safety of the Home Intravenous Antibiotic Therapy (HIAT) program in the district of Haifa and Western Galilee in Northern Israel. METHODS: We checked all the medical records of all the patients who had been treated at home with intravenous antibiotics during 1999. We reviewed the mean clinical diagnosis, aetiological agent, type of antibiotic given, complications and cost evaluation. RESULTS: During 1999, 250 patients received 284 courses of HIAT. The total duration of treatments was 3404 days; 61% of the patients were referred from clinical departments from one of the medical centres in our area. Soft-tissue infections and osteomyelitis were the most common clinical diagnoses at 40%. Pseudomonas aeruginosa was the most frequent pathogen presented and Ceftazidine the most common antimicrobial agent prescribed. The HIAT program saved $815 000 during 1999. Only minor complications were present. CONCLUSIONS: HIAT is effective, safe, comfortable for the patients, and has an important economical impact.

[Hospital-at-home as a solution for the treatment requirements of acute exacerbation in multiple sclerosis].

Cooperation between the Multiple Sclerosis center at the Carmel medical center and the Hospital-at-Home (H.H) department of the continuing care unit in the Haifa and Western Galilee district of the Clalit Health Services has made it possible to give methylprednisolone intravenously to Multiple Sclerosis (M.S) patients during an acute exacerbation of the disease, in their home. In this study, we describe the joint work of the two centers. We have summarized 30 treatment courses given to 26 patients in their homes, following referral by the M.S. center, in the year 1999. The aims of the study included assessing satisfaction, safety and cost-effectiveness in a treatment course in the HH framework, as compared to the same treatment being conducted in the framework of hospitalization in various neurological departments, as was done in the past in the same group of patients. The expenses involved in HH for this group of patients were only 14% of the parallel treatment in the hospital (a savings of 86%). The treatment has proven to be extremely safe. There were no side-effects that required returning patients to the hospital, and the treatment was given in conditions of maximum comfort for the patient and his family. A telephone survey was conducted, which compared the satisfaction with the HH treatment, and the burden caused the patient's family to prior hospitalization for the same treatment. For all of the parameters examined, greater satisfaction was distinctly proven in the HH treatment. In light of these findings, we can conclude that giving methylprednisolone intravenously to M.S patients during an acute exacerbation, in the HH framework, is a safe and cost effective treatment, preferred by the patient and his family.

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.

[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.

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.

Referrals of patients by family physicians to consultants: a survey of the Israeli Family Practice Research Network.

OBJECTIVE: We aimed to analyse factors influencing referral of patients by primary care physicians to specialist consultants at the beginning of the era of direct access to specialists in Israel. METHODS: We carried out a study of referrals by family physicians to specialists over a continuous period of 3 months. Twenty-four certified family physicians filled in a questionnaire detailing referrals during the study period. All patients were referred for consultation to a specialist at regional speciality clinics or hospital out-patient departments. RESULTS: Ten physicians met the study conditions. In 1140 of 10896 (10.5%) visits, patients were referred to specialist consultants. The percentage of referral ranged from 7.4 to 15.9%. The difference between the physicians with the lowest and highest rates of referral was statistically significant (P < 0.0001). The variance in referral rates was not explained by significant differences in physician or practice variables. The types of specialists to whom the most referrals were made were orthopaedic surgeons, ophthalmologists, dermatologists, ear, nose and throat, general surgeons and plastic surgeons. There was a significant correlation between the type of specialist and the age of the patient. Older patients were referred more frequently to urologists, cardiologists and ophthalmologists, while younger patients were referred more frequently to ear, nose and throat specialists and gynaecologists (P < 0.01). CONCLUSIONS: The results of this study can be used as an aid for decision makers in the health services for determining policy. Direct access to some specialties might be appropriate, but not to all. Adoption of a policy based on these findings could lead to reduced health care costs by reducing the burden on hospital emergency rooms. It might also increase patient satisfaction in that the patients will have greater freedom of choice. On the other hand, more appropriate training of family physicians and more extensive self- and peer-quality assurance will increase the primary physician's knowledge and ability to diagnose and treat a broad range of problems and improve the level of care.

Adenosine for the treatment of paroxysmal supraventricular tachycardia in full-term and preterm newborn infants.

Adenosine has been approved for intravenous use for paroxysmal supraventricular tachycardias (SVT) in adults and children. However, effectiveness and safety of intravenous adenosine in preterm infants are not well established. Thirteen episodes of SVT in three preterm and two full-term neonates were treated with intravenous adenosine. All had narrow QRS tachycardia at 230 to 260 beats/min. Adenosine prepared as a sterile 1 mg/mL solution was given as an intravenous bolus starting at 0.05 mg/kg, and increased by 0.05 mg/kg until tachycardia was terminated. Termination of tachycardia was achieved within 12 to 25 seconds in all patients. In one, termination of SVT was followed by temporary suppression of the sinus node, followed by resumption of normal sinus rhythm. No other side effects were noted. Adenosine is a safe and effective agent for treating preterm infants with SVT. However, further investigation of adenosine in this group of patients is warranted.

A peer review programme to audit the management of hypertensive patients in family practices in Israel.

We introduced and evaluated a self-audit and peer review programme for the management of hypertension in eight urban and rural family medicine practices in northern Israel between January 1991 and December 1992. Changes in the level of blood pressure control and the effect of peer review and self-audit on physicians' management of hypertension were evaluated. Participating physicians were provided with feedback throughout the course of the study. Six hundred and seventy-four hypertensive patients from a total adult population of 4445 patients (15%) were identified in eight practices and followed for two years. The percentage of uncontrolled hypertensives (blood pressure > or = to 160/95 mmHg) decreased from 46.8% at the beginning of the sstudy to 34.3% at its conclusion (P = 0.01). Data on prevalence of hypertension were analysed by participating clinics (prevalence range 8.5-24.6%) and by type of community (rural or urban). In rural communities 50% of the hypertensives were > or = to 70 years of age, compared with 39.5% in the urban practices. Differences in prescribing practices among participating physicians were discussed during peer review group meetings and changes in prescribed medications for hypertension were evaluated. We conclude that this method of self-audit and peer review is effective in improving the management of patients with hypertension in family medicine practices. It was implemented at a minimal cost, is feasible in busy practices and can be generalized to the management of other chronic diseases in the community.

Proposed changes in malpractice law. Are they enough?

Most of the healthcare reform plans recently introduced in Congress propose changes in medical liability law. Will these changes suffice to stem the rising tide of malpractice suits? How will healthcare professionals be affected by the legislation? The authors, a physician and an attorney, address these and other questions as they analyze the malpractice provisions of five plans and offer their own recommendations for reform.

Family physicians' involvement with dying patients and their families. Attitudes, difficulties, and strategies.

OBJECTIVE: To determine family physicians' perceptions of the difficulty in caring for dying patients and how prepared they are to provide such care relative to strategies used with difficulties encountered, personal need for support and development, and cooperation with other caregivers. DESIGN: Exploratory. SETTING: Physicians' offices. SUBJECTS: Thirty-five randomly selected family physicians (doctors of medicine and doctors of osteopathy) representative of family physicians practicing in Franklin County, Ohio. INTERVENTIONS: None. MAJOR OUTCOME MEASURES: A semistructured interview guide corresponding to a three-dimensional theoretical model developed prior to the study was used to determine family physicians' perceptions regarding care of dying patients and their families. The three dimensions include family physicians' involvement with dying patients and their families, their personal needs and development, and their cooperation with other caregivers. RESULTS: Participants agreed that the care of dying patients and their families is an important and special component of practicing family medicine. Generally seeing themselves as adequately prepared, they still found such care difficult and desired more education and training to increase comfort of their patients and of themselves. Their perceptions regarding the care of dying patients and their families could be categorized in terms of communication as part of the care process, family issues, legal and ethical issues, coordination of care, physicians' feelings, and physicians' influence and support. CONCLUSIONS: Family physicians require formal training in death issues and need to find a way to maximize learning through personal experiences. Discussion of cases in a support group may be beneficial.

The family physician's role in caring for the dying patient and family: a comprehensive theoretical model.

Care for the dying patient is a difficult task which arouses many emotions in all participants. Many physicians feel inadequately prepared to cope with the many diverse challenges. A three-dimensional model is described which intends to help physicians better define their role in caring for dying patients. The model comprises direct involvement with the dying patients and their families, the physician's own needs and personal development and the co-operation with other care-givers. This model can be implemented at three levels, according to the physician's experience, skills, feelings, and the situation. The model can serve as a basis for extensive research and as a foundation for curricular innovation for students, residents and continuing medical education.

[Characteristics of urgent house calls in an urban clinic].

Urgent house calls during regular clinic hours constitute a significant burden on the family physician's workload. It is the impression of the staff of this clinic that many patients use this service incorrectly, so that ordering an urgent house call often leads to a direct confrontation between the patient and his physician. During a 4-month period questionnaires were filled out by the physician before and after every visit described as "urgent" by the caller. There was a huge gap between the physician's and the patient's concept of what constitutes an urgent situation. However, in many cases the physician justified the visit. This survey emphasizes the importance of house calls and justifies them, but not always as to their urgency. As a result of this survey, we are now designing a program to improve communication when an urgent house call is ordered, in order to minimize the gap between the physician's and his patient's understanding and expectations of the necessity and urgency of the visit.

[The problematic physician-patient encounter].

The medical encounter between the physician and the patient may sometimes be difficult, with either or both participants feeling uncomfortable. To try to understand what transpires during an unsatisfactory encounter, it is essential to examine the parts played by the patient and the physician and the context in which the encounter takes place. A problematic patient for one physician may be an ordinary one for another. However, there are some patients who are difficult for most physicians. In this article, the traits of problematic patients are described, as well as personal and professional characteristics of physicians and various circumstances not directly related to the participants that may make the encounter difficult (overcrowded agenda, an external problem which a participant brings to the encounter, and so on). To improve the quality of the medical encounter the physician must first be aware when there is a problem. He must then identify the various causes of the "mutual disagreement" and the participant responsible for it. He must also increase his awareness of his own emotional reactions in order to arrive at a satisfactory personal solution.