Familiarity breeds discontent: senior hospital doctors' attitudes towards complementary/alternative medicine.

UNLABELLED: Studies have shown that many general medical practitioners refer their patients to complementary/alternative medicine (CAM) practitioners and believe in the therapeutic benefit of these modalities. However, there is less information concerning the beliefs and practices of senior hospital doctors. OBJECTIVES: In view of the increasing institutionalization of CAM and moves to incorporate CAM into secondary and tertiary healthcare settings, the objective of this study is to understand the attitudes and practices of senior hospital doctors, a sector whose members are often responsible for formulating and implementing institutional policy. DESIGN AND SETTING: A questionnaire was administered to 294 directors of hospital departments and their deputies on their attitudes and practices concerning CAM. Response rate was 70%. Almost all general hospitals in Israel participated in the study. RESULTS: The findings show, in general, that while senior hospital physicians in Israel hold positive attitudes towards CAM, they are not well disposed towards co-operation with CAM practitioners. Incorporating a CAM clinic into the hospital site does not seem to enhance clinical co-operation between conventional physicians and CAM practitioners. In hospitals that had functioning CAM clinics, doctors were consistently and significantly more opposed to co-operation with CAM than in hospitals without CAM clinics.

Dietary calcium supplementation for preventing colorectal cancer and adenomatous polyps.

BACKGROUND: Several dietary factors have been considered to be involved in the increasing incidence of colorectal cancer in industrialised countries. Experimental and epidemiological evidence has been suggestive but not conclusive for a protective role for high dietary calcium intake. Intervention studies with colorectal cancer as an endpoint are difficult to perform owing to the large number of patients and the long follow-up required; studies using the appearance of colorectal adenomatous polyps as a surrogate endpoint are therefore considered in reviewing the existing evidence. OBJECTIVES: This systematic review aims to assess the effect of supplementary dietary calcium on the incidence of colorectal cancer and the incidence or recurrence of adenomatous polyps. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, the Cochrane Colorectal Cancer Group specialised register, MEDLINE, Cancerlit , and Embase, to July 2007. The reference lists of identified studies were inspected for further studies, and the review literature was scrutinized. SELECTION CRITERIA: Randomised controlled trials of the effects of dietary calcium on the development of colonic cancer and adenomatous polyps in humans are reviewed. Studies of healthy adults and studies of adults at higher risk of colon cancer due to family history, previous adenomatous polyps, or inflammatory bowel disease were considered; data from subjects with familial polyposis coli are excluded. The primary outcomes were the occurrence of colon cancer, and occurrence or recurrence of any new adenomas of the colon. Secondary outcomes were any adverse event that required discontinuation of calcium supplementation, and drop-outs before the end of the study. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data, assessed trial quality and resolved discrepancies by consensus. The outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI). The data were combined with the fixed effects model. MAIN RESULTS: Two studies with 1346 subjects met the inclusion criteria. Both trials were well designed, double - blind, placebo controlled trials, included participants with previous adenomas. The doses of supplementary elemental calcium used were 1200 mg daily for a mean duration of 4 years, and 2000 mg/day for three years. The rates of loss to follow -up were 14 % and 11%. For the development of recurrent colorectal adenoma, a reduction was found (OR 0.74, CI 0.58,0.95) when the results from both trials were combined. AUTHORS' CONCLUSIONS: Although the evidence from two RCTs suggests that calcium supplementation might contribute to a moderate degree to the prevention of colorectal adenomatous polyps, this does not constitute sufficient evidence to recommend the general use of calcium supplements to prevent colorectal cancer.

Dietary calcium supplementation for preventing colorectal cancer and adenomatous polyps.

BACKGROUND: Several dietary factors have been considered to be involved in the increasing incidence of colorectal cancer in industrialised countries. Experimental and epidemiological evidence has been suggestive but not conclusive for a protective role for high dietary calcium intake. Intervention studies with colorectal cancer as an endpoint are difficult to perform owing to the large number of patients and the long follow-up required; studies using the appearance of colorectal adenomatous polyps as a surrogate endpoint are therefore considered in reviewing the existing evidence. OBJECTIVES: This systematic review aims to assess the effect of supplementary dietary calcium on the incidence of colorectal cancer and the incidence or recurrence of adenomatous polyps. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, the Cochrane Colorectal Cancer Group specialised register, MEDLINE, Cancerlit, and Embase, to April 2002. The reference lists of identified studies were inspected for further studies, and the review literature was scrutinized. SELECTION CRITERIA: Randomised controlled trials of the effects of dietary calcium on the development of colonic cancer and adenomatous polyps in humans are reviewed. Studies of healthy adults and studies of adults at higher risk of colon cancer due to family history, previous adenomatous polyps, or inflammatory bowel disease were considered; data from subjects with familial polyposis coli are excluded. The primary outcomes were the occurrence of colon cancer, and occurrence or recurrence of any new adenomas of the colon. Secondary outcomes were any adverse event that required discontinuation of calcium supplementation, and drop-outs before the end of the study. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data, assessed trial quality and resolved discrepancies by consensus. The outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI). The data were combined with the fixed effects model. MAIN RESULTS: Two studies with 1346 subjects met the inclusion criteria. Both trials were well designed, double - blind, placebo controlled trials, included participants with previous adenomas. The doses of supplementary elemental calcium used were 1200 mg daily for a mean duration of 4 years, and 2000 mg/day for three years. The rates of loss to follow -up were 14 % and 11%. For the development of recurrent colorectal adenoma, a reduction was found (OR 0.74, CI 0.58,0.95) when the results from both trials were combined. AUTHORS' CONCLUSIONS: Although the evidence from two RCTs suggests that calcium supplementation might contribute to a moderate degree to the prevention of colorectal adenomatous polyps, this does not constitute sufficient evidence to recommend the general use of calcium supplements to prevent colorectal cancer.

Dietary calcium supplementation for preventing colorectal cancer and adenomatous polyps.

BACKGROUND: Several dietary factors have been considered to be involved in the increasing incidence of colorectal cancer in industrialised countries. Experimental and epidemiological evidence has been suggestive but not conclusive for a protective role for high dietary calcium intake. Intervention studies with colorectal cancer as an endpoint are difficult to perform owing to the large number of patients and the long follow-up required; studies using the appearance of colorectal adenomatous polyps as a surrogate endpoint are therefore considered in reviewing the existing evidence. OBJECTIVES: This systematic review aims to assess the effect of supplementary dietary calcium on the incidence of colorectal cancer and the incidence or recurrence of adenomatous polyps. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, the Cochrane Colorectal Cancer Group specialised register, MEDLINE, Cancerlit, and Embase, to April 2002. The reference lists of identified studies were inspected for further studies, and the review literature was scrutinized. SELECTION CRITERIA: Randomised controlled trials of the effects of dietary calcium on the development of colonic cancer and adenomatous polyps in humans are reviewed. Studies of healthy adults and studies of adults at higher risk of colon cancer due to family history, previous adenomatous polyps, or inflammatory bowel disease were considered; data from subjects with familial polyposis coli are excluded. The primary outcomes were the occurrence of colon cancer, and occurrence or recurrence of any new adenomas of the colon. Secondary outcomes were any adverse event that required discontinuation of calcium supplementation, and drop-outs before the end of the study. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data, assessed trial quality and resolved discrepancies by consensus. The outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI). The data were combined with the fixed effects model. MAIN RESULTS: Two studies with 1346 subjects met the inclusion criteria. Both trials were well designed, double - blind, placebo controlled trials, included participants with previous adenomas. The doses of supplementary elemental calcium used were 1200 mg daily for a mean duration of 4 years, and 2000 mg/day for three years. The rates of loss to follow -up were 14 % and 11%. For the development of recurrent colorectal adenoma, a reduction was found (OR 0.74, CI 0.58,0.95) when the results from both trials were combined. REVIEWER'S CONCLUSIONS: Although the evidence from two RCTs suggests that calcium supplementation might contribute to a moderate degree to the prevention of colorectal adenomatous polyps, this does not constitute sufficient evidence to recommend the general use of calcium supplements to prevent colorectal cancer.

A comparison of videotape and audiotape assessment of patient-centredness in family physicians' consultations.

The aim of this study was to compare videotape and audiotape assessments of doctors' patient-centred behaviour in primary care consultations. The patient-centredness scale of Henbest and Stewart was used to measure the quality of 856 doctor-patient interactions in 258 consultations performed by 47 primary care physicians recorded on videotape. Assessments were performed once using only the sound track and a second time using both the sound and video-tracks. On a nominal quality scale of 0-3, the average score for all consultations was 1.94 (S.D. 0.63) by audio assessment, and 1.94 (S.D. 0.59) by video assessment (P<0.8). There was excellent agreement between audio and video scores over a wide range of scores. Little information (<5%) was lost when using audiotape compared to videotape. It was technically easier to assess the video recordings. Audio recording is equivalent to video recording for the assessment of patient-centredness using the scale of Henbest and Stewart in primary care consultations.

Home visits to the housebound patient in family practice: a multicenter study. Israeli General Practice Research Network.

BACKGROUND: Most countries today are experiencing an accelerated pace of population aging. The management of the elderly housebound patient presents a special challenge to the family physician. OBJECTIVES: To investigate a series of home visits to housebound patients, the therapeutic procedures used, the equipment needed, and the diagnostic conclusions reached. METHODS: The details of 379 consecutive home visits to housebound patients were recorded by 91 family doctors serving 125,000 patients in Israel. RESULTS: The average age of the patients was 76.1 years. The vast majority of the visits were during office hours (94%). In 24.1% it was the doctor who decided to make the home visit on his/her own initiative. The most common initial reason for a home visit was undefined general symptoms, but the doctor was usually able to arrive at a more specific diagnosis after the visit. Medications were prescribed in 59.1% of the visits, and in 23.5% the medication was administered directly by the physician. The commonest drugs used were analgesics and antibiotics. In 19.3% of visits no action at all, other than examination and counseling, was undertaken. The equipment needed included prescription pads (73%), a stethoscope (81%), sphygmomanometer (74.9%), and otoscope/torch (30.6%). Only 15% of visits resulted in referral to hospital. CONCLUSIONS: Home visits to housebound patients serve as a support to caregivers, provide diagnostic information, and help the family with the decision as to when hospitalization is appropriate. The specific medical cause for the patient being housebound had little effect on the process of home visiting.

Diabetes and ischemic heart disease among Yemenite immigrants in Israel.

BACKGROUND: The pattern of diabetes and ischemic heart disease among emigrants from pre-industrialized societies to more developed countries may be explained by both genetic and environmental factors. OBJECTIVES: To describe and interpret the pattern of diabetes and ischemic heart disease among Yemenite immigrants in Israel and their second-generation offspring. METHODS: Medical record charts of adult Yemenites were surveyed in a primary care health center, and the data were compared with prevalence rates derived from a non-Yemenite population. RESULTS: There was a marked excess of non-insulin dependent diabetes mellitus among Yemenite immigrants over 45 years of age, but not of hypertension or ischemic heart disease. Yemenites with diabetes were far less likely to develop ischemic heart disease than non-Yemenites with diabetes (odds ratio for non-Yemenites compared with Yemenites, 3.5; confidence interval 1.54 < OR < 7.77). CONCLUSIONS: There was less of an association between diabetes and ischemic heart disease among Yemenites. This finding requires further investigation of the relative roles of genetic and environmental factors.

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.

Variations among examiners in family medicine residency board oral examinations.

OBJECTIVES: This study was designed to describe the variation in marking tendencies among different examiners in an oral examination. DESIGN: Marks awarded in a family practice board examination between 1984 and 1996 were analysed, relating to 5328 examination sessions graded by 94 examiners. Examiners were ranked by the rates at which they awarded 'fail', 'pass' or 'distinction' grades. The effects of examiners' gender, experience, academic rank, regional affiliation and country of qualification on examiner behaviour were studied. SETTING: National Family Medicine Examination Board, Scientific Council, Israel Medical Association. SUBJECTS: Oral examiners. RESULTS: Eighteen per cent of examiners were classified as 'tough', being in the lowest tertile for 'distinction' rates and the highest tertile for 'failure' rates; 19% were classified as 'mild'; 52% were 'regular', falling in the middle tertile for both distinction and failure rates. Four per cent of examiners were in the top tertile for both distinctions and failures, labelled 'extremists', and 6% were in the bottom tertile for both, and were labelled 'noncommittal'. Higher failure rates were associated with examiners' academic rank, experience and graduation from an English-speaking medical school. CONCLUSIONS: Examiners differ significantly in their degree of severity. Those who demonstrate clearly deviant patterns of grading should be withdrawn. Candidates should be presented with a balanced panel of examiners, and a degree of standardization of content should be introduced into oral examinations.

Illness and treatment perceptions of Ethiopian immigrants and their doctors in Israel.

OBJECTIVES: Patient-provider misunderstandings arising from disparate medical and cultural concepts can impede health care among immigrant populations. This study assessed the extent of disagreement and identified the salient problems of communication between Israeli doctors and Ethiopian immigrant patients. METHODS: Semistructured interviews were conducted with 59 Ethiopian immigrants. Self-reports of health status and effectiveness of treatment were compared with evaluations by the primary care physician and supplemented by qualitative data from descriptions of illness, observations of medical visits, informant interviews, and participant observations conducted by the anthropologist. RESULTS: Health status and effectiveness of treatment were rated significantly higher by the doctor than by the patients. Low doctor-patient agreement occurred mainly for illnesses with stress-related or culture-specific associations. Qualitative data suggested that more long-term immigrants may alter their expectations of treatment but continue to experience symptoms that are culturally, but not biomedically, meaningful. CONCLUSIONS: Misunderstandings between immigrant patients and their doctors emerge from the biomedical system's limitations in addressing stress-related illnesses and from culture-based discrepancies in concepts of illness and healing. Including trained translators in medical teams can reduce medical misunderstandings and increase patient satisfaction among immigrant populations.

[Abnormal liver function tests in the primary care setting].

Results of laboratory tests ordered during a primary care encounter may reveal findings of abnormal liver function tests, including elevated liver enzymes, hyperbilirubinemia, hypoalbuminemia or abnormal coagulation tests. The object of this study was to describe the spectrum of these liver function test (LFT) abnormalities in primary care. Results of all laboratory tests ordered during 10 months in an urban primary care clinic were retrospectively reviewed and the medical charts of patients with abnormal LFTs were studied. In 217/1088 (20%) of the tests at least 1 LFT abnormality was found in 156 patients. New diagnoses were made in 104 patients. The main diagnostic groups were: non-alcoholic fatty liver changes, Gilbert's disease, acute infectious hepatitis, alcoholic liver disease and cirrhosis and hepatotoxic drug injury. In 60 patients the physician classified the abnormality as negligible and not associated with significant disease. However, an abnormal test that had been ordered for evaluation of a specific complaint, was indeed likely to represent significant disease (X2 = 29.5, p < 0.001). We conclude that finding abnormalities in liver function tests is common in the primary care clinic but does not often indicate significant liver disease.

Attitudes of primary care physicians to the management of asthma and their perception of its relationship to patients' work.

The results of a questionnaire on the attitude of family physicians and general practitioners to the management of asthma, and their perception of the relationship between working conditions and asthma are reported. Family physicians were three times more likely than general practitioners to treat asthmatic patients themselves, without referral to a specialist. However, there were no other major differences between these two groups regarding the weight they attributed to the occupational factor in asthma. Overall, both groups routinely asked patients about their job (78%) and exposure at work (75%), but at least in half the cases this issue was not followed-up to determine if occupation-related counselling or problem management were necessary. Differences in the primary care of asthmatics were also noted between physicians in Israel and America. In Israel, physicians tended to explain everything to the patients at the initial visit, and then leave them to cope on their own unless the episodes remained uncontrolled, whereas their American counterparts continued their educational activities in subsequent visits as well. We conclude that family medicine residency training in Israel, despite the inclusion of courses and lectures on occupational health in general and on respiratory diseases in particular, does not sufficiently emphasize this subject. Clinicians should be trained to take a more in-depth and active approach to this problem in order to avoid misdiagnosis and improve prevention.

The influence of SCUD missile attacks on the utilization of ambulatory services in a family practice.

The consulting load in a family practice exposed to SCUD missile attacks during the 1991 Gulf War was compared with the equivalent period in 1990. The rate of visits was cut by half, with a relative and absolute increase in psychological consultations, and a decrease in consultations for infectious and respiratory conditions. There were more urgent consultations and fewer planned appointments. It is suggested that the stress of the SCUD missile attacks led to a reduction in consultations for trivial disorders, but an increase in the anxiety level of the population.

What family physicians need in their doctor's bag.

Our objective was to determine what family physicians need in their doctor's bag for urgent and non-urgent house calls. In a prospective survey, family physicians completed a structured report form after consecutive house calls, recording what equipment they needed for each. Thirteen doctors from two urban practices, making a total of 111 house calls, took part. Frequency of reported need of diagnostic equipment, therapeutic agents and administrative supplies was measured. Items required more than 70% of the time were: stethoscope; sphygmomanometer; patient's medical chart; and prescription pad. All other items were required in less than 30% of house calls. We conclude that doctors should carry a stethoscope, sphygmomanometer and prescription pad with them at all times; the patient's medical chart is also essential. Additional equipment should be accessible as prepared kits and taken as needed, depending on the particular patient's problem.

The development of family medicine in Israel.

Israeli family medicine provides an example of the accelerated development of a new discipline. This development occurred in a highly dynamic and rapidly growing society against a background of conflicting cultural traditions within the health care field. The developmental stages included: 1) the preponderance of specialists over generalists, 2) the introduction of family medicine teaching into the undergraduate medical curriculum, 3) the achievement of family medicine's independence from the status of a branch of internal medicine or community medicine, 4) the development of the residency training programs, and 5) the establishment of a national academic infrastructure. This paper analyzes the unsolved problem of gaining significant numbers of university academic appointments. Also, two major challenges for the future are examined: 1) the integration of preventive care into family practice, and 2) the exposure of primary care to competition from hospital-based specialists in an atmosphere of increasing commercialism. The Israeli experience forms a basis for comparison for family medicine in other countries.

Should nurses in Israeli primary care clinics be expected to manage streptococcal throat infections?

INTRODUCTION: Legal regulations in Israel allow nurses to perform only limited clinical procedures. OBJECTIVE: To determine the probability of streptococcal infection in adults with sore throat, as assessed clinically by standard nursing procedures. DESIGN: Using throat culture as the standard, the contribution of various clinical findings (fever, exudate, erythrocyte sedimentation rate (ESR), white blood count) to the determination of the diagnosis of streptococcal infection was assessed, using logistic regression analysis. SETTING: Israeli general practice. PATIENTS: 100 consecutive adult patients presenting with a red, sore throat. RESULTS: Six patients showed the full clinical picture of exudate, increased ESR and leukocytosis, with an 82% probability of streptococcal infection. Forty-nine patients showed none of these three findings, and only one of them (among the three patients with rhinitis) had a positive throat swab. Forty-five patients showed an intermediate clinical picture which did not provide a reliable basis for the diagnosis or exclusion of streptococcal infection. Fever alone did not significantly (P < 0.05) predict streptococcal infection. CONCLUSIONS: Nurses may safely discharge adult patients with a red, sore throat without antibiotic treatment only if they have no additional signs or symptoms. The few patients with all the clinical findings may be treated with antibiotics without a throat swab. All other patients should be referred for examination by a doctor.

Consultations with rabbis.

OBJECTIVE: To explore the reasons for and the content of consultations between patients and the clergy on medical matters. SETTING: four general practices in central Israel. DESIGN: exploratory descriptive study of 42 patients who had consulted rabbis. They were asked about what they expected from the consultation, what happened and with what effect. RESULTS: 90% of consultations were with rabbis who had earned a special reputation for dealing with medical problems, rather than with a local community rabbi. Reproductive problems, psychiatric, and general surgical problems accounted for the majority of consultations. Most patients went to the rabbi for advice or direction; 25% went for a blessing. In general it was recommended that they change doctors, even when this was not the advice they expected. Only rarely was there any contact between the rabbi and the doctor. In over half the cases the idea of consulting the rabbi came from family or friends rather than from the patients. Being actively religious did not seem to be a necessary characteristic of patients who consulted rabbis. CONCLUSIONS: Rabbis in a medical role do not seem to practise faith healing as such, but rather act to strengthen a patient's faith in the treatment. The medical system does not always succeed in engendering this faith, either in the patient or in the family.

Attitudes of family physicians to nonconventional therapies. A challenge to science as the basis of therapeutics.

Eighty-nine Israeli family physicians responded to a questionnaire on their experience with nonconventional therapies (NCTs) and their opinions about the scientific basis and clinical efficacy of these treatments. They were also asked whether they thought that NCTs should be incorporated into regular medical practice. Seventeen percent of the physicians had formal training in some form of NCT and 11% thought the scientific basis of these treatments was sound; however, a majority (54%) thought they may be clinically useful. Forty-two percent had referred patients for such treatments. The majority thought that NCTs should be incorporated into medical practice. Our survey suggests that many physicians are not using the tools of scientific critical appraisal in forming their views on NCTs.

The epidemiology of benign leukopenia in Yemenite Jews.

Blood counts of 372 Yemenite Jews of all ages were reviewed in order to clarify the epidemiology of benign leukopenia. Twenty-one percent of the total leukocyte counts were below 5.0 x 10(3) cells/mm3. Neutropenia < 2.0 x 10(3) was present in 15.4% of the blood counts, significantly lowering the average neutrophil count in the population. There was no significant variation in the prevalence of neutropenia with age. In contrast, the average lymphocyte and erythrocyte counts were normal. We conclude that leukopenia among Yemenite Jews should be defined as neutropenia rather than leukopenia, and that the phenomenon is only half as common as was previously noted. Since the prevalence of neutropenia remains constant across all age-groups, in immigrants as well as among the Israeli-born, it is unlikely to be an acquired condition.