Public and private patients in Jerusalem hospitals: who operates on whom?

BACKGROUND

Debate continues in Israel as to whether to allow patients in public hospitals to choose their physician in return for an additional, out-of-pocket payment. One argument against this arrangement is that the most senior physicians will devote most of their time to private patients and not be sufficiently available to public patients with complex cases.

OBJECTIVES

To analyze the patterns of surgical seniority in Jerusalem hospitals from a number of perspectives, including the extent to which: a) opting for private care increases the likelihood of being treated by a very senior surgeon; b) public patients undergoing complex operations are being treated by very senior surgeons, c) the most senior surgeons allocate a significant portion of their time to private patients.

METHODS

Demographic and clinical data were retrieved from the operating room records of three of the public hospitals in Jerusalem for all 38,840 operations performed in 2001. Of them, roughly 6000 (16%) were performed privately. Operations were classified as "most complex," "moderately complex" and "least complex" by averaging the independent ratings of eight medical and surgical experts. The surgeon's seniority was graded as "tenured" (tenured board-certified specialists, including department heads), "senior" (non-tenured board-certified specialists), and "residents." For each operation, we considered the seniority of the lead surgeon and of the most senior surgeon on the surgical team.

RESULTS

The lead surgeon was of tenured rank in 99% of the most complex private cases and 74% of the most complex public cases, in 93% of the moderately complex private and 35% of the moderately complex public cases, and in 92% of the least complex private and 32% of the least complex public cases. The surgical team included a tenured physician in 97%, 66%, and 53% of the most complex, moderately complex, and least complex public operations, respectively. In both private and public cases, a board-certified (tenured or senior) specialist was a member of the surgical team for almost all of the most complex and moderately complex operations. On average, over half of the operations in which the lead surgeon was a department head were performed on public patients. Among tenured surgeons, those who spent more hours than their colleagues leading private operations also tended, on average, to spend more hours leading public operations.

CONCLUSIONS

Private patients have an advantage over public patients in terms of the seniority of the lead surgeon. However, there is also substantial involvement of very senior surgeons in the treatment of public patients, particularly in those cases that are most complex.

Viewpoint: suggestions for a shift in teaching clinical skills to medical students: the reflective clinical examination

How medical students are taught physical examination (PE) skills appears to have changed little since the 1950s. Textbooks are organized according to organ systems and describe methods of eliciting and recording history and PE data using a routine format. In many medical schools, the preclinical teaching programs for clinical examination skills similarly emphasize an orderly collection of data. Teaching students to use diagnostic reasoning is postponed until students have learned history-taking and PE skills. The authors propose three modifications to this educational approach. First, rather than performing the clinical examination using a routine format, students should be encouraged to form diagnostic hypotheses early on while listening to the patient's narrative, and conduct the subsequent search for history and PE data in a reflective way in order to confirm or refute these hypotheses. Second, the authors propose that interviewing patients and conducting the PE be taught by one-on-one tutoring until students achieve mastery. Last, they suggest that the PE be guided not only by students' diagnostic hypotheses, but also by patients' expectations. These modifications are consistent with current trends in medical education that encourage a reflective practice and problem-based learning (PBL), and they also introduce medical students to the precepts of clinical reasoning. The authors suggest that challenging students to seek specific physical findings may increase the likelihood of detecting findings when they are present, and may transform patient interviewing and conducting the PE from routine activities into intellectually exciting experiences.

Promoting a biopsychosocial orientation in family practice: effect of two teaching programs on the knowledge and attitudes of practising primary care physicians

The bio-psychosocial (BPS) approach to patient care has gained acceptance in medical education. However, reported teaching programs rarely describe the efficacy of alternative approaches to continuing medical education aimed at promoting a BPS approach. The objective was to describe and evaluate the effect of two teaching programs on learners' BPS knowledge, management intentions, patient-centered attitudes, professional self-esteem, burnout, work related strain and mental workload. The learners were Israeli general practitioners. The first ("didactic") program consisted of problem-based reading assignments, lectures and discussions. The second ("interactive") program consisted of reading assignments, lectures and discussions, in addition to role-playing exercises, Balint groups and one-to-one counseling by a facilitator. One month before and six months after the teaching interventions, we used structured questionnaires to test for knowledge, management intentions (responses to questions, such as "what would you tell a patient with ...") and attitudes. Both programs led to measurable improvement in knowledge, intentions, patient-centered attitudes and self-esteem. The interactive teaching approach improved significantly more the learners' professional self-esteem and intentions than the didactic approach. Self-reported burnout significantly increased after the program. It is concluded that teaching intervention enhanced a BPS orientation and led to changes in knowledge, intentions, self-esteem and attitudes. An interactive method of instruction was more effective in achieving some of these objectives than a didactic one. The observed increase in burnout was unexpected and requires further study and confirmation.

Enhancing self-awareness in medical students: an overview of teaching approaches

Self-awareness is an individual's tendency to pay attention to his or her own emotions, attitudes, and behavior in response to specific situations. In the case of physicians, self-awareness is their insight into how their emotional makeup influences patient care. Conceivably, such insight may improve doctors' professional performance. The authors review published approaches aimed at enhancing the self-awareness of medical students and draw attention to some problems in these approaches that call for further research. Published teaching programs of self-awareness may be classified as direct or indirect. The primary objective of direct programs is to promote students' insight into their own feelings and attitudes by classroom instruction or small-group discussions, during which students share with their peers their emotional responses to various clinical experiences. The primary objective of indirect approaches is to teach clinical skills, such as patient interviewing, patient counseling, and self-assessment. It has been claimed that these programs also enhance self-awareness by drawing students' attention to differences between students' assessment of their own performance and the assessments of their instructors and patients. Both types of programs should be given consideration for inclusion into the medical curriculum. However, since presently available evidence does not allow educators to identify an optimal teaching program, more study is needed concerning the effectiveness of the various approaches to teaching self-awareness. Specifically, an effort should be made to ascertain that the benefit of the direct approaches exceeds their cost in terms of time, teacher training, and-possibly-student embarrassment.

What is empathy, and how can it be promoted during clinical clerkships?

The ability of medical students to empathize often declines as they progress through the curriculum. This suggests that there is a need to promote empathy toward patients during the clinical clerkships. In this article, the authors attempt to identify the patient interviewing style that facilitates empathy and some practice habits that interfere with it. The authors maintain that (1) empathy is a multistep process whereby the doctor's awareness of the patient's concerns produces a sequence of emotional engagement, compassion, and an urge to help the patient; and (2) the first step in this process--the detection of the patient's concerns--is a teachable skill. The authors suggest that this step is facilitated by (1) conducting a "patient-centered" interview, thereby creating an atmosphere that encourages patients to share their concerns, (2) enquiring further into these concerns, and (3) recording them in the section traditionally reserved for the patient's "chief complaint." Some practice habits may discourage patients from sharing their concerns, such as (1) writing up the history during patient interviewing, (2) focusing too early on the chief complaint, and (3) performing a complete system review. The authors conclude that sustaining empathy and promoting medical professionalism among medical students may necessitate a change in the prevailing interviewing style in all clinical teaching settings, and a relocation of a larger proportion of clinical clerkships from the hospital setting to primary care clinics and chronic care, home care, and hospice facilities, where students can establish a continuing relationship with patients.

Effect of a biopsychosocial approach on patient satisfaction and patterns of care

BACKGROUND

There is a growing tendency to include in medical curricula teaching programs that promote a biopsychosocial (BPS) approach to patient care. However, we know of no attempts to assess their effect on patterns of care and health care expenditures.

OBJECTIVE

To determine whether 1) a teaching intervention aiming to promote a BPS approach to care affects the duration of the doctor-patient encounter, health expenditures, and patient satisfaction with care, and 2) the teaching method employed affects these outcomes.

METHODS

We compared two teaching methods. The first one (didactic) consisted of reading assignments, lectures, and group discussions. The second (interactive) consisted of reading assignments, small group discussions, Balint groups, and role-playing exercises. We videotaped patient encounters 1 month before and 6 months after the teaching interventions, and recorded the duration of the videotaped encounters and whether the doctor had prescribed medications, ordered tests, and referred the patient to consultants. Patient satisfaction was measured by a structured questionnaire.

RESULTS

Both teaching interventions were followed by a reduction in medications prescribed and by improved patient satisfaction. Compared to the didactic group, the interactive group prescribed even fewer medications, ordered fewer laboratory examinations, and elicited higher scores of patient satisfaction. The average duration of the encounters after the didactic and interactive teaching interventions was longer than that before by 36 and 42 seconds, respectively.

CONCLUSIONS

A BPS teaching intervention may reduce health care expenditures and enhance patients' satisfaction, without changing markedly the duration of the encounter. An interactive method of instruction was more effective in achieving these objectives than a didactic one.

Overcoming barriers to teaching the behavioral and social sciences to medical students

Most U.S. medical schools offer courses in the behavioral and social sciences (BSS), but their implementation is frequently impeded by problems. First, medical students often fail to perceive the relevance of the BSS for clinical practice. Second, the BSS are vaguely defined and the multiplicity of the topics that they include creates confusion about teaching priorities. Third, there is a lack of qualified teachers, because physicians may have received little or no instruction in the BSS, while behavioral and social scientists lack experience in clinical medicine. The authors propose an approach that may be useful in overcoming these problems and in shaping a BSS curriculum according to the institutional values of various medical schools. This approach originates from insights gathered during their attempts to teach various BSS topics at four Israeli medical schools. They suggest that medical faculties (1) adopt an integrative approach to learning the biomedical, behavioral, and social sciences using Engel's "biopsychosocial model" as a link between the BSS and clinical practice, (2) define a hierarchy of learning objectives and assign the highest priority to acquisition of clinically relevant skills, and (3) develop clinical role models through teacher training programs. This approach emphasizes the clinical relevance of the BSS, defines learning priorities, and promotes cooperation between clinical faculty and behavioral scientists.

[Barriers to the fair allocation of healthcare resources]

The gap between infinite healthcare needs and finite health resources imposes on practicing physicians a dual commitment to patients' needs and to the fair allocation of health care resources. The ethical principles of a fair allocation of resources are egalitarianism, utilitarianism and a transition from individual to group-based ethics. These principles are ambiguous and occasionally conflicting. Their implementation is further impeded by practice norms, such as private practice by physicians employed by public institutions, incentives for physicians to save, and marketing of clinical interventions of unproven efficacy. Proposed approaches to these barriers to the fair allocation of resources include respect of patient autonomy with full disclosure of the limitations in the services provided by the health plan; adherence to clinical practice guidelines; and an open access for patients to second medical opinion. I believe that the fairness of resource allocation may be further improved by the prohibition of private practice by physicians employed in public health care institutions, and by enhancement of physicians' self-awareness of subconscious discrimination against some patients.

Predictors of patient dissatisfaction with emergency care

BACKGROUND

Patient feedback is increasingly being used to assess the quality of healthcare.

OBJECTIVE

To identify modifiable independent determinants of patients dissatisfaction with hospital emergency care.

METHODS

The study group comprised a random sample of 3,152 of the 65,966 adult Israeli citizens discharged during November 1999 from emergency departments in 17 of the 32 acute care hospitals in Israel. A total of 2,543 (81%) responded to a telephone survey that used a structured questionnaire. The dependent variables included: hospital characteristics, patient demographic variables, patient perception of care, self-rated health status, problem severity, and outcome of care. The dependent variable was dissatisfaction with overall ED experience on a 1-5 Likert-type scale dichotomized into not satisfied (4 and 5) and satisfied (1, 2 and 3).

RESULTS

Eleven percent of the population reported being dissatisfied with their emergency room visit. Univariate analyses revealed that dissatisfaction was significantly related to ethnic group, patient education, hospital identity and geographic location, perceived comfort of ED facilities, registration expediency, waiting times, perceived competence and attitudes of caregivers, explanations provided, self-rated health status, and resolution of the problem that led to referral to the ED. Multivariate analyses using logistic regressions indicated that the four most powerful predictors of dissatisfaction were patient perception of doctor competence and attitudes, outcomes of care, ethnicity, and self-rated health status.

CONCLUSIONS

Attempts to reduce dissatisfaction with emergency care should focus on caregiver conduct and attitudes. It may also be useful to improve caregiver communication skills, specifically with ethnic minorities and with patients who rate their health status as poor.

Physicians' attitudes toward litigation and defensive practice: development of a scale

The authors' threefold purpose in this article was to (a) propose a model of the relationship between the emotional aspects of physicians' attitudes to medical errors (e.g., fear of litigation) and their functional consequences (e.g., tendency to defensive practice); (b) develop a measure of some of these attitudes; and (c) provide empirical support for some of the relationships in the model. Medical students and physicians responded to a questionnaire concerning their attitudes toward uncertainty and medical error. The dependent variables were two dimensions of attitudes to uncertainty ("reluctance to disclose uncertainty" and "stress from uncertainty") and four dimensions of attitudes to medical error ("fear of litigation," "support for self-regulation," "tendency to defensive practice," and "self-disclosure of errors"). Stress from uncertainty correlated with fear of malpractice litigation and defensive practice. They concluded that interventions that aim to increase physicians' tolerance of uncertainty may also reduce their fear of malpractice litigation and their tendency to defensive practice.

A step-wise role playing approach for teaching patient counseling skills to medical students

We describe a step-wise role playing approach to bedside teaching during the clinical training of medical students. The objective of this approach is to teach them the skills which are required to practice patient-centered medicine. "Patient-centered medicine" refers to a style of practice which relates to patients' needs rather than to the doctor's own plan, and which moves from professional control to patient empowerment. Our approach is based on: (a) interviews with real patients, and (b) re-play of doctor--patient encounters in small group teaching sessions using the instructor (a physician) as a simulated patient, while a student assumes the role of the physician. The objective of the simulation is to assess the student's ability to provide health-related information, involve patients in making clinical decisions and plan their management in a manner which suits their preferences and lifestyle. The medical background of the instructor who simulates the patient eliminates barriers in communication and allows these objectives to be easily accomplished. The discussion which follows, attempts to: (a) identify discrepancies between the optimal counseling which was offered to the simulated patient and that offered to the real patient; and (b) show that although inevitable, these discrepancies are not irreducible. We have no formal evaluation of our approach in terms of whether it achieved its objective, produced changes in students' attitudes and bedside manners, or in terms of students' ratings of the teaching approach. However, student participation and occasional verbal feedback have indicated that the teaching intervention may be a valid contribution to the clinical training of medical students and that it may be of use for other clinical instructors.

Teaching doctor-patient interviewing skills using an integrated learner and teacher-centered approach

BACKGROUND AND OBJECTIVE

We describe an approach for the resolution of difficulties that some preclinical medical students appeared to have when acquiring patient interviewing skills.

SETTING

Two medical schools in Israel.

TYPE OF STUDY

Descriptive.

OBSERVATIONS

Students' difficulties were related to the inconsistency between the patient-centered approach that was emphasized in the preclinical teaching programs and the disease-centered (biomedical) approach that was practiced on the wards. Others were confused by ambiguous vocabulary and by the multiplicity of rules that they had to remember. Still others appeared to resent attempts to teach them what they thought was elementary courtesy, to reject counterintuitive interviewing rules, and to be bored by the repetitive nature of the practice sessions. TEACHING INTERVENTION: We used an integrated learner- and teacher-centered approach, which is based on the premise that students learn more effectively when autonomous and self-motivated than when responding to instructions from others. Rather than the students being lectured, they were asked to identify the problems in doctor-patient communication and to propose solutions. We conducted live demonstrations of patient- and disease-centered interviews and encouraged students to discuss the advantages and disadvantages of each of them. Lastly, we supervised students as they interviewed patients with increasingly difficult communication problems.

CONCLUSIONS

The described approach is consistent with current theories of adult learning. It permits the instructor's input and also supports students' autonomy in identifying and resolving problems in patient interviewing and in choosing the balance between patient- and disease-centered interviewing styles according to the patient's needs. The feasibility of our approach is conditional on the availability of instructors who feel comfortable conducting group discussions, are familiar with the literature on doctor-patient relations, and are experienced enough to demonstrate different interviewing techniques using live patients.

Patient perception of involvement in medical care during labor and delivery

BACKGROUND

Patients who feel involved in their treatment have better outcomes than those who do not.

OBJECTIVE

To identify determinants of perceived patient involvement in obstetric care.

METHODS

A retrospective study was undertaken in 1,452 (83%) of 1,750 women sampled in November 1995 from maternity wards of 14 general hospitals in Israel. A postal and telephone survey using a self-administered questionnaire included the following variables: hospital (identity number), patients' age, self-reported complications, previous deliveries, education, ethnicity, and number of obstetric interventions performed and/or considered. The main outcome measured was the reported involvement in decisions for obstetric interventions.

RESULTS

Reported full involvement varied from 72% for epidural analgesia to 13% for forceps/vacuum extraction. Factor analysis identified two dimensions of perceived involvement: one for "routine" interventions (enema, monitoring, IV line and episiotomy), which are performed in Israel mostly by midwives, and another for "special" interventions (forceps/vacuum extraction, epidural or other analgesia, and cesarian section) performed by physicians. Logistic regression identified hospitals, younger age, number of interventions, and Arab ethnicity as correlates of a perceived non-involvement in decisions for "special" interventions.

CONCLUSIONS

Clinical setting, age and ethnicity affected patient perception of involvement in decisions for obstetric interventions.

Determinants of hospital utilization: the situation in Israel and selected countries

BACKGROUND

In 1995 hospital costs constituted about 42% of the health expenditures in Israel. Although this proportion remained stable over the last decade, hospital discharge rates per 1,000 population increased, while hospitalization days per 1,000 population and average length of stay declined.

OBJECTIVE

To gain an insight into the forces behind these changes, we compared the trends in hospital utilization in Israel with those in 21 developed countries with available data.

MATERIALS AND METHODS

Our data were derived from The "Hospitals and Day Care Units, 1995" report by the Health Information and Computer Services of the Israel Ministry of Health, and the Organization for Economic Cooperation and Development Health Data, 98. We examined the numbers of acute care hospital beds, of patients on dialysis and of doctors' consultations, health expenditures and age structure of the population in 1995 or closest year with available data, as well as changes in DRs, HDs and ALOS between 1976 and 1995.

RESULTS

In Israel the DRs increased from 130 in 1976 to 177 in 1995 (36%), HDs declined from 992 to 818 (18%), and ALOS declined from 7.60 to 4.51 days (41%). Relative to other countries, in 1995 Israel had the lowest ALOS; low HDs similar to those in the UK, Portugal, Spain, the USA and Sweden; and intermediate DRs similar to those in Belgium, Germany, Sweden and Australia. The number of acute care beds per 1,000 population was directly related to HDs (r = 0.954, P = 0.000) and to DRs (r = 0.419, P = 0.052). Health expenditures (% of the gross national product) correlated with the number of patients on dialysis per 1,000,000 population (r = 0.743, P = 0.000). Between 1976 and 1995, HDs and ALOS declined in most countries, however the trends in DRs varied from an increase by 119% in the UK to a decline by 29% in Canada. CONCLUSIONS AND HYPOTHESES: The increase in DRs in Israel from 1976 to 1995 was shared by many but not all countries. This variability may be related to differences in trends in local practice norms and in available hospital beds. If the number of patients on dialysis is a valid index for use of expensive treatment modalities, the correlation of health expenditures with the number of patients on dialysis suggests that the use of expensive technology is a more important determinant of health care costs than the age of the population or hospital utilization. Since the use of expensive technology is highest during the first few days in hospital, decisions about health care policy should consider the possibility that the savings incurred by a further decline in HDs and ALOS may be offset by a possible increase in per diem hospital costs and in health care expenditures after discharge from hospital.

Serum total cholesterol and cardiovascular mortality in Israeli males: the CORDIS Study. Cardiovascular Occupational Risk Factor Determination in Israeli Industry

BACKGROUND

The degree to which serum total cholesterol predicts cardiovascular disease is uncertain. While most authors have placed TC among the most powerful risk indicators of CVD, some have claimed that it predicted CVD in women only, or even not at all.

OBJECTIVE

To determine the predictive value of serum total cholesterol relative to diabetes, smoking, systolic blood pressure and body mass index (kg/m2), for cardiovascular disease mortality in 3,461 occupationally active Israeli males.

METHODS

A prospective follow-up was carried out for the years 1987-1998 to determine the effect of age, smoking habits, a history of diabetes, SBP, BMI and TC, at entry, on CVD mortality.

RESULTS

There were 84 CVD deaths during a total of 37,174 person-years follow up. The hazard ratios (95% confidence intervals) for CVD mortality with respect to variables at entry were: diabetes 5.2 (2.1-13.2), age 2.2 (1.7-2.9), smoking 1.3 (1.0-1.8), SBP 1.4 (1.1-2.0), TC 1.5 (1.0-2.1) and BMI 1.2 (0.7-2.2). Among non-obese, non-diabetic, normotensive subjects the hazard ratio of TC adjusted for age and smoking was 1.16 (1.09-1.22) per 10 mg/dl. In the remaining subjects it was 1.04 (0.98-1.12) only. There was a significant interaction between TC and diabetes, hypertension or obesity (P = 0.003).

CONCLUSIONS

In this population of Israeli males we found an interaction between TC and other risk indicators for CVD. Confirmation is required for the unexpected finding that the predictive value of TC for CVD mortality among non-diabetic, non-obese and normotensive subjects exceeded that among subjects with either of these risk factors.

Inconsistencies in the classification of preventive interventions

BACKGROUND AND OBJECTIVE

Preventive measures are commonly classified into primary (prevention of a disease from occurring), secondary (screening of asymptomatic persons with a view of early detection and treatment of disease), and tertiary (treatment of patients with a view of palliation, cure, rehabilitation, prevention of relapse, or prevention of complications). The objective of the present survey was to assess the adherence to this classification in a sample of abstracts of scientific publications.

METHOD

We searched the literature (key terms prevention and primary, secondary, or tertiary) and identified 317 abstracts describing various preventive interventions. We tabulated the level of prevention as defined in the abstract, by what was done, to whom, and why.

MAIN FINDINGS

There was a considerable variability in the way the various levels of prevention were defined in the reviewed abstracts.

CONCLUSIONS

The definitions of the levels of prevention are not specific enough to be appropriately used by all. We suggest, therefore, to define clinical interventions by their objective, target population, and type ("reduction of mortality of patients with symptomatic ventricular ectopy by beta-blockers"), rather than in terms of level of prevention ("tertiary prevention of ventricular ectopy").

Determinants of hospital utilization: the content of medical inpatient care in Israel

BACKGROUND

The increasing utilization of general internal medicine hospital wards in Israel during the last decade is a source of concern for health policy makers.

OBJECTIVES

To report on the distribution of selected main and secondary diagnoses among GIM inpatients, and to estimate the proportion of disorders for which appropriate care in the community will reduce the need for hospital admissions and re-admissions.

METHODS

Data from the Health Information and Computer Services of the Israel Ministry of Health (national hospitalization database) for a one year period were analyzed by distribution of diagnostic entities (ICD-9-CM) in GIM and in medical subspecialty wards.

RESULTS

Of the 313,824 discharges from hospital divisions of medicine in 1995, 256,956 (81.9%) were from GIM and 56,868 (18.1%) from specialty wards. Main and secondary discharge diagnoses were available for 188,807 GIM and 35,992 specialty patients. Of all main diagnoses in GIM wards, 27% were coded as "general or systemic symptoms and signs" or as "abnormal laboratory or ill defined manifestations" (ICD-9-CM codes 780-799, 276,277), and heart diseases comprised another 27%. The remaining main diagnoses covered almost all medical conditions. The combined proportion of "ambulatory care sensitive hospital admissions" (bronchial asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, diabetes) constituted 12% of all main diagnoses in GIM, and respiratory symptoms or signs comprised another 11%. A by-product of this analysis was an insight into the experience of undergraduate medical students in GIM.

CONCLUSIONS

Assuming that 12-75% of admissions for "ambulatory care sensitive disorders" are preventable, an improved review before hospital discharge and a closer outpatient follow-up may reduce the load on GIM wards by 1-17%. This wide range justifies controlled trials to determine the effect of improved community care on hospital utilization. GIM wards offer valuable learning opportunities, but they cannot be a substitute for primary care clinics. The unexplained high proportion of GIM inpatients who were discharged with an unspecified main diagnosis could be detrimental for the accuracy of hospitalization statistics, and justifies investigation by chart audits into physicians' habits of documentation.

Hospital readmissions as a measure of quality of health care: advantages and limitations

We reviewed the recent literature on hospital readmissions and found that most of them are believed to be caused by patient frailty and progression of chronic disease. However, from 9% to 48% of all readmissions have been judged to be preventable because they were associated with indicators of substandard care during the index hospitalization, such as poor resolution of the main problem, unstable therapy at discharge, and inadequate postdischarge care. Furthermore, randomized prospective trials have shown that 12% to 75% of all readmissions can be prevented by patient education, predischarge assessment, and domiciliary aftercare. We conclude that most readmissions seem to be caused by unmodifiable causes, and that, pending an agreed-on method to adjust for confounders, global readmission rates are not a useful indicator of quality of care. However, high readmission rates of patients with defined conditions, such as diabetes and bronchial asthma, may identify quality-of-care problems. A focus on the specific needs of such patients may lead to the creation of more responsive health care systems for the chronically ill.

Tolerance of uncertainty of medical students and practicing physicians

BACKGROUND

Tolerance of uncertainty is believed to be an important attribute of practicing physicians. This study attempts to (1) estimate how medical students perceive physicians' tolerance of uncertainty and (2) measure the tolerance of uncertainty of practicing physicians.

RESEARCH DESIGN

Cross-sectional.

SETTING AND SUBJECTS

Medical students (n = 113) and practicing physicians (n = 151) at the Faculty of Health Sciences, Ben-Gurion University, Israel.

MEASURES

A self-administered, Hebrew version of an instrument developed in the United States.

INDEPENDENT VARIABLES

Age, gender, seniority (year of study for students or years in practice for physicians), country of birth for students or of graduation for physicians, and physicians' specialty.

DEPENDENT VARIABLES

Two dimensions, which were identified by factor analysis: reluctance to disclose uncertainty and stress from uncertainty.

RESULTS

The estimates of physicians' stress from uncertainty by first-year students aged <22 years were higher than those by first-year students aged > or =22 years. There were no significant differences in the way junior and senior medical students perceived physicians' tolerance of uncertainty. Stress from uncertainty was higher in female physicians (P = 0.028) and in graduates of the former Soviet Union (P = 0.044) than among male physicians and Israeli graduates, respectively. Reluctance to disclose uncertainty was higher among graduates of the former Soviet Union (P = 0.003) and among psychiatrists (P = 0.021) than among Israeli graduates and other specialties, respectively.

CONCLUSIONS

The reliability and factor structure of the instrument were replicated. The previously reported differences in tolerance of uncertainty between women and men and between local and foreign graduates were confirmed. Physicians' tolerance of uncertainty appeared to be higher than that attributed to them by students. The expected age-related differences in perception of clinical uncertainty were not detected between junior and senior medical students.

Referral to occupational medicine clinics and resumption of employment after myocardial infarction

Rehabilitation after acute myocardial infarction (AMI) consists of education, exercise, and an encouragement to return to work (RTW). This study attempts to (1) determine whether the time interval between AMI and the visit at occupational medicine (OM) clinics predicts resumption of full employment, and (2) estimate the incidence of work-related recurrent AMI after RTW. We followed 216 consecutive AMI patients at a single OM clinic. The independent variables were clinical and personal data, physical workload and time between AMI, and first visit to the OM clinic. The outcome variables were full employment 24 months after the acute event and recurrent AMI during this period. Of all patients, 168 attempted RTW. Of these, 18 stopped working subsequently. Of the remaining 150 patients, 54 returned to part-time work and 96 were employed full-time after 2 years. Logistic regression indicated that a failure to resume full employment was independently associated with diabetes, older age, Q wave AMI, angina before AMI, heavy work, and a late visit to the OM clinic. For each month's delay in referral to the OM clinic, there was a 30% decrease in the chance for full employment 24 months after AMI. Six (4%) of the 150 patients who resumed employment sustained a recurrent AMI, two of them while at work. A delayed referral to the OM clinic was associated with work disability after AMI. Late referrals to OM clinics should receive a more intensive and sustained rehabilitation than early referrals. Whether an earlier referral to OM clinics will result in increased RTW rates is unknown. Patients who attempted to resume employment had a 1.2% risk of a recurrent ischemic event at their workplace.

Significance of low hematocrit levels in asymptomatic young adults: results of 15 years follow-up

HYPOTHESIS

Periodic complete blood counts are not recommended for disease prevention in low-risk, non-pregnant adults. Consequently, there are few follow-up studies of the prevalence of incidentally detected anemia in asymptomatic subjects and its significance for their well-being. The objective of this survey is to determine the frequency of anemia and its predictive value for disease over a 15-yr annual follow-up of a cohort of asymptomatic young males, selected for physical fitness and intelligence.

METHODS

One thousand Israeli airmen aged 18-30 yr at entry into this historical-prospective study in 1968 were used as subjects. Hematocrit (Hct) levels were examined annually. On the average each subject had 13.2 tests in the course of the 15 yr follow-up. We arbitrarily defined anemia as a Hct of 40% or less on two or more tests, and compared the prevalence of diagnosed disorders in subjects with and without anemia.

RESULTS

During follow-up, anemia was found in 125 (12.5%) of the subjects. On successive annual examinations of the same individual Hct levels varied by 3% or more in 3.5% of those without anemia, and in 10.5% of those with anemia. The frequency of diagnosed disorders, excluding inter-current infections and trauma, was 25.6%, and 10.9% among those with and without anemia, respectively (OR = 2.8, 95% CI 1.8-4.6). Anemia was associated with inflammatory bowel disease (OR = 12.1, 95% CI 2.3 78.6) and malignancy (OR = 3.6, 95% CI 1.1-10.7). It preceded diagnosis only in one case with Waldenstr 246 m's macroglobulinemia, in one case of inflammatory bowel disease and two cases of myocardial infarction.

CONCLUSIONS

A finding of anemia doubled the likelihood of chronic disease. However, it had a limited predictive value for subsequent morbidity and did not lead to detection of treatable disorders or to disorders that might otherwise have endangered flight safety. Fluctuations of up to 3% in Hct over time may be viewed as normal in young males.

Healthy volunteer effect in industrial workers

Volunteers for epidemiological research, have lower mortality rates than non-volunteers, thereby producing a bias referred to as the "healthy volunteer effect" (HVE). Occupationally active persons have been similarly shown to have a reduced mortality relatively to the general population (the "healthy worker effect"). To determine whether a HVE exists in occupationally active persons, we followed for 8 years a cohort of Israeli male industrial employees, of whom 71.6% agreed to participate in 1985 in screening examinations for cardiovascular disease. We calculated standardized mortality ratios (SMRs) of the entire cohort relative to the general population, and compared the mortality among participants with that of the non-participants. Over 8 years follow up, SMRs were 78% for the entire cohort, 71% for participants and 99% for non-participants. Participants were older than non-participants and worked more commonly in smaller factories. A proportional hazard model indicated that after adjusting for these variables, the all cause mortality hazard ratio among participants and non-participants was 0.69 (95% CI = 0.51-0.94). During the first and last two years of the 8-year follow-up there were 39.6 and 30.0 age-adjusted deaths per 10,000 person-years among participants, and 58.6 and 51.5 respectively among non-participants. We conclude that the HVE occurs in occupationally active persons, and that it may persist for up to 8 years follow-up.

Smoking cessation and body mass index of occupationally active men: the Israeli CORDIS Study

OBJECTIVES

This study estimated weight gain after smoking cessation and identified factors attenuating this gain.

METHODS

We conducted a prospective follow-up of 1209 male factory workers for 2 to 4 years. The independent variables were smoking habits. age, sports activity, education, alcohol consumption, ethnicity, duration of follow-up, and body mass index (BMI, kg/m2) at entry. The dependent variable was increase in BMI during follow-up.

RESULTS

The mean age-adjusted BMI at entry into the study was 26.6 kg/m2 among past smokers and 25.4 kg/m2 among current smokers. There were no differences in BMI between those who quit less than 3 years before entry and those who quit more than 6 years before entry. During follow-up, the average increase in BMI was 0.07 kg/m2 among never smokers, 0.19 kg/m2 among smokers who had stopped smoking before entry, 0.24 kg/m2 among current smokers, and 0.99 kg/m2 among those who stopped smoking after entry. Cessation of smoking after entry predicted an increased gain in BMI; older age, a higher BMI at entry, sports activity, and alcohol consumption attenuated this gain.

CONCLUSIONS

The increased rate of weight gain after smoking cessation is transient. However, the weight gained is retained for at least 6 years.