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.

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.

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.

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.

A clinical approach to alternative medicine.

Our patients receive and will continue to receive alternative therapies regardless of our stand on the issue. While scientific scrutiny may slowly bring a few of them into the medical mainstream, the number of alternative techniques is unlikely to dwindle significantly. Primary care physicians can help their patients deal with them by knowing the local alternative medical community, by gentle counseling about the potential for harm in certain techniques, and by steering patients toward practitioners with a reasonable scope of practice that matches the patient's belief system. In this way, the physician may confidently support the patient's belief in the healing power of whatever therapy--alternative or traditional--is chosen.

Risk management in the community: lessons for family medicine.

Three polyurethane factories in Israel were examined using a combination of qualitative and quantitative methodologies. The study contrasts the effects of differing factory social and economic organization on occupational health and safety conditions as well as workers' attitudes and awareness. The central focus of the research addresses how each factory and community manages the risks associated with a particular industrial process. Surprisingly, the results show that the worker-owned and -operated plant, where knowledge and control of hazards was broadly shared and awareness high, had the worst safety, health, and hygiene conditions and outcomes. Worker involvement does not ensure worker protection and safety. These findings can be explained only by a careful examination of the social, economic, cultural and environmental settings in which they are embedded. Such an approach is well suited to family medicine research and training since it emphasizes the role of context on illness and disease.

Expectations and outcomes after hip fracture among the elderly.

Hip fractures among the elderly are a common occurrence, with high social and personal costs. Sequelae not infrequently include loss of independent functioning, permanent disability, and death. This prospective study of a cohort of eighty recently diagnosed "hardy" hip fracture patients examines initial rehabilitation expectations using a combination of methods. The study addresses the relationship between initial expectations and changes in ambulatory status from prefracture to three months post-fracture. The importance of previous experience with illness is also explored. Participants who had positive expectations for recovery and those who had greater previous experience were likely to have less negative change in ambulation from prefracture to three months, and better overall ambulation at three months. The findings suggest a relationship between patient expectations for recovery and actual recovery of ambulation, and support the heretofore "clinical impression" that cognition and affect influence the course of rehabilitation after hip fracture.

A developmental model of ethnosensitivity in family practice training.

Cross-cultural medicine is a natural and important part of family practice. Unfortunately, its acceptance and implementation into family practice training programs has been limited. This paper presents a developmental model of ethnosensitivity in family practice training which assesses a trainee's ability to grasp cross-cultural issues and suggests strategies for improving cross-cultural communication and practice skills.

Finding meaning after the fall: injury narratives from elderly hip fracture patients.

Hip fractures occur frequently among the elderly, often with severe medical, psychological and social repercussions. This research takes a new look at hip fracture rehabilitation, focusing on meanings and post-fracture prognostic indicators. An innovative methodological approach to narrative analysis is employed which combines ethnographic and epidemiologic techniques. Analyses of injury narratives from 80 elderly subjects interviewed soon after initial hospitalization are presented, focusing on three categories of meaning: explanatory models, sense of disability, and futurity. Insights from these narratives, as well as from questionnaires and observations, shed light on the experience of hip fracture for the elderly. In addition, aspects of the initial narratives are considered in relation to ambulation outcomes at 3 and 6 months. Those individuals who perceive their problem in a more external or mechanical fashion (caused by the environment) show greater improvement in ambulation at 3 and 6 months relative to those who show no evidence of this thinking or who perceive it as an internal or organic problem (in terms of disease or illness). Greater improvement in ambulation at 3 and 6 months is also noted for subjects whose perception of disability was consistent with more autonomy, independence, and a sense of connection with the world around them. The present study demonstrates the potential utility of narrative analysis as a data reduction approach. It also suggests the possibility of new psychosocial prognostic factors for hip fracture rehabilitation.