Burnout among family medicine residents: a cross-sectional nationwide study

BACKGROUND

In addition to pressures typical of other medical professions, family physicians face additional challenges such as building long-term relationships with patients, dealing with patients' social problems, and working at a high level of uncertainty. We aimed to assess the rate of burnout and factors associated with it among family medicine residents throughout Israel.

METHODS

A cross sectional study based on a self-administered questionnaire.

RESULTS

Ninety family medicine residents throughout Israel completed the questionnaire. The rate of clinically significant burnout, assessed by the composite Shirom-Melamed Burnout Questionnaire score, was 14.4%. In univariate analyses several personal and professional characteristics, as well as all tested psychological characteristics, showed significant associations with burnout. However, in the multivariable logistic regression only psychological work-related characteristics (work engagement, psychological flexibility (reverse scoring), and perceived work-related stress) were significantly associated with burnout at OR (95% CI) = 0.23 (0.06-0.60), 1.31 (1.10-1.71), and 1.16 (1.05-3.749), respectively.

CONCLUSION

The integration of burnout prevention programs into academic courses during residency could explain the relatively low prevalence of burnout among family medicine residents in this study. Given the strong association of burnout with psychological characteristics, further investment in burnout prevention through targeted structured courses for residents should be encouraged.

[COMMON TREATMENT FOR ACUTE TONSILLITIS IN THE COMMUNITY]

BACKGROUND

Streptococcal tonsillitis among adults is a common diagnosis. There is wide agreement regarding the recommended treatment, which is Phenoxymethyl Penicillin (Penicillin V) 1000 mg daily (usually 500 mg BID for 10 days).

OBJECTIVES

Description of the variability of routine antibiotic treatment prescribed by family physicians in the community for the treatment of acute tonsillitis (which represents a common diagnosis in primary care), and observation of the prescribed antibiotics adherence to the guidelines.

METHODS

Nine primary care physicians in urban clinics of Clalit Health Services, were included in the study. Information regarding 320 adult patients, 18 years of age or older, treated by them, was collected. Patients allergic to penicillin were not included. Comparison between the different medications was performed with relevant statistical tests.

RESULTS

Data regarding 95 men (30% of patients) and 224 women (70% of patients) was collected; the age range was 24 - 86 years old (average 38 years). Streptococcus group A was sensitive to all antibiotics prescribed; 70% (n=224) were prescribed with Penicillin V and the rest were given prescriptions for other antibiotics. From those who were given Penicillin V, 54% (n=121) were prescribed the recommended dosage (500 mg BID); 34% (n=77) were prescribed double dosage (1000 mg BID), whereas the rest of the patients received prescriptions for other dosages. Difference in treatment regimens was observed among the participating physicians regarding the choice and the dosage of the antibiotics they prescribed. In the medical files, there were no explanations regarding the different antibiotics or dosages.

CONCLUSIONS

Streptococcus A tonsillitis is a common diagnosis with wide consensus regarding the recommended antibiotic treatment. In spite of this consensus, there is significant prescribing variability among different physicians. This is emphasized by the fact that all the physicians who were included in the study work in urban clinics with similar characteristics. In view of the variation among primary care physicians regarding antibiotic prescription for a very common diagnosis, we see a need to investigate other treatment protocols for other common diagnoses. This is in order to ensure proper care and avoiding health complications while saving funds.

Improving the doctor-patient relationship in China: the role of balint groups

OBJECTIVE

Doctor-patient relationships in China have been deteriorating for the past 10 years. Many Chinese doctors are involved in tense and conflictual doctor-patient relationships. Most patients do not trust doctors or other medical staff and physical attacks on these professionals have become a common event. The Balint group offers a better understanding of the doctor-patient relationship in a safe environment and relieves the doctors from the daily stress.

METHOD

This article (1) describes the specifics of Balint work in China, (2) reports experiences from the first International Balint Conference in China, and (3) compares these experiences with the doctor-patient relationship described by Michael and Enid Balint in the 1950s.

RESULTS

Chinese doctors have a great need to communicate, to share their own feelings of powerlessness, helplessness, frustration, and anger. The Balint method is highly appreciated in China. All participants experienced the 2 1/2-day meeting as very helpful. Also, in China, Balint work as relationship work in the analytical group process fosters the ability for introspection alongside openness, unconscious processes, "thinking outside the box," "courage of one's own stupidity," and "beginner's spirit," thus promoting the individuation, the "small but significant change in the personality of the doctor."

CONCLUSIONS

Perhaps Balint work in China is a contribution to the integration of traditional Chinese virtues: benevolence, tolerance, magnanimity, and prudence with modern medicine. Balint work could be an alternative to the outcome-oriented pressure to perform and to the machine paradigm of biomedicine.

Lipid control in patients with coronary heart disease treated in primary care or cardiology clinics

BACKGROUND

Guidelines recommend low-density lipoprotein-cholesterol (LDL-C) target of <70 mg/dL in patients with coronary disease. However, this goal is not achieved in many patients.

OBJECTIVES

We compared LDL-C control in patients with coronary disease treated by a primary care physician or with the addition of a cardiologist.

METHODS

Included were patients with coronary disease who had full lipid profile. Primary end points included the percentage of patients who achieved the LDL-C goals of <100 mg/dL and <70 mg/dL.

RESULTS

Of the 27,172 patients, 12,965 (47.7%) were followed only by a primary care physician and 14,207 (52.3%) were also followed by a cardiologist. Overall, 18,366 patients (67.6%) achieved the LDL-C goal of <100 mg/dL, and 6517 patients (24%) achieved the LDL-C goal of <70 mg/dL. Patients followed by a cardiologist more frequently achieved the LDL-C goal of <100 mg/dL (74.3% and 60.3%; P < .0001, in patients treated by a cardiologist or by a primary care physician, respectively), as well as the lower LDL-C goal of <70 mg/dL (27.2% and 20.4%; P < .0001, in patients treated by a cardiologist or by a primary care physician, respectively). Differences in LDL-C control remained significant after a multivariate adjustment. Patients followed by a cardiologist were more commonly treated with highly potent statins and with non-statin cholesterol-lowering drugs.

CONCLUSIONS

Among patients with coronary disease, those followed by a cardiologist receive a more aggressive antilipid treatment and more frequently achieve lipids goals. Nevertheless, the disappointingly poor lipid control in both groups warrants an effort to improve adherence for guidelines in both primary care and cardiology clinics.

New-onset diabetes in elderly subjects: association between HbA1c levels, mortality, and coronary revascularization

OBJECTIVE

New-onset diabetes mellitus (DM) in elderly patients is associated with increased risk of diabetes complications and mortality. It is unknown whether glycemic control in this population influences the mortality risk.

RESEARCH DESIGN AND METHODS

The current study was conducted using the computerized database of the Sharon-Shomron District of Clalit Health Services in Israel. Included in the study were subjects 65 years of age and above with new-onset DM. The primary outcome measures were all-cause mortality and coronary revascularization procedures with either percutaneous coronary intervention or coronary artery bypass grafting.

RESULTS

Participants (n = 2,994) were stratified into four groups according to their mean HbA1c levels during the follow-up period (<6.5% [48 mmol/mol], 6.5-6.99% [48-52 mmol/mol], 7-7.49% [53-57 mmol/mol], and ≥7.5% [58 mmol/mol]). During a mean follow-up of 5.54 ± 2.1 years, 1,173 (39.17%) participants died and 285 (9.51%) underwent coronary revascularization. An HbA1c level >7.5% (58 mmol/mol) was associated with a significantly increased all-cause mortality rate (hazard ratio [HR] 1.74 [95% CI 1.2-1.8], P < 0.0001). This difference remained statistically significant after a multivariate model adjusted for the conventional cardiovascular risk factors and for the use of hypoglycemic agents and statins. Kaplan-Meier survival plots revealed lower survival rates in this group of patients. Coronary revascularization rates were highest among subjects with HbA1c 6.5-6.99% (48-52 mmol/mol) (HR 1.6 [1.01-2.4], P < 0.05) and lowest in patients with HbA1c ≥7.5% (58 mmol/mol).

CONCLUSIONS

An HbA1c level >7.5% (58 mmol/mol) is associated with increased risk for all-cause mortality and with a lower revascularization rate in elderly patients with new-onset DM.

Use of humour in primary care: different perceptions among patients and physicians

PURPOSE

(1) To explore the frequency with which humorous behaviour and statements occur in family medicine practice in Israel, and (2) to quantitatively assess the correlation between the subjective perceptions of humour in medical encounters between patients and physicians.

METHOD

In a cross sectional study, two populations (doctors and patients) were surveyed with paired structured questionnaires completed immediately after primary care practice visits. Two hundred and fifty consecutive encounters from 15 practices were sampled. The physician questionnaire was self administered, and patient questionnaire was administered by a trained research assistant.

RESULTS

A mean of 16.7 questionnaires was completed per physician (range 6-20). The physicians reported having used some humour in only 95 encounters (38%), whereas almost 60% of patients agreed with the statement, "The doctor used some humour during the visit". At the same time, for specific encounters, the agreement between patients' perception and physicians' perceptions on the use of humour, although not completely by chance (p = 0.04), is low (kappa = 0.115). Patient characteristics (age, education, gender, family status, mother tongue, self perceived heath status, stress, mood, and expectations) were not related to the degree of agreement between the patients' and physicians' perceptions.

CONCLUSION

Humour was used in a large proportion of encounters, independently of patient characteristics. Patients seem to be more sensitised to humour than physicians, probably because of their high stress level during medical encounters. Cultural differences may also play a part. Physicians should be made aware of this magnifying effect, and the issue should be discussed in medical schools.

[The creation of a national faculty development program in Israel for family physicians]

University Departments from many countries recruit their faculty members for academic duties without prior formal training (specific for their jobs). This has been the common approach in Israel. Other countries however, have created faculty development (FD) programs to help new faculty accomplish their new tasks. This article describes the creation of the first National Faculty Development Program in Israel for Family Physicians. The main goals of a comprehensive FD program are to improve vitality in education, promote academic excellence and develop professional and organizational leadership. In 1998, the Israeli Society of Teachers in Family Medicine decided to develop a National Program to deal with basic FD requirements. Family Physicians and educationalists worked together at its development and cooperated in co-teaching. The program was launched in 2001 and we are now in the process of evaluating the first year and the development of the second course. We chose a format similar to the program from the University of Toronto. Twenty-three family physicians enrolled in the course. Half of the participants were born and trained in medicine in Israel. After completing the first year of this program, both participants and teachers provided positive feedback and requests were received for a second course for new participants.

Choosing primary care? Influences of medical school curricula on career pathways

In countries in which a primary care-oriented system has developed, general practitioners, family physicians, and other primary care doctors are the keystone of an approach that aims to achieve high quality and satisfaction with relatively low costs. Despite this new trend, medical schools still produce excessive numbers of sub-specialists rather than primary care physicians. Among multiple reasons influencing a career choice either towards or away from primary care (institutional, legislative, and market pressures), the present article discusses ways in which medical school curricula may affect students in their perceptions of the role of primary care physicians. Since students are greatly influenced by the cultures of the institutions in which they train, the negative attitude of a university towards family medicine may negatively affect the number of students going into this specialty. Examples from Israeli faculties are presented.

The family physician, the patient and the hospital

BACKGROUND

Family physicians coordinate the care of their patients and follow them in a longitudinal manner. Do they have a role to play when their patients are hospitalized? Does the system of care expect them to play a role, and how does it support or integrate it?

OBJECTIVES

To discuss the various models of relations between hospital and primary care physicians in the world as compared to those in Israel.

METHOD

Short cases are reported describing the author's personal experiences and difficulties encountered in a family practice.

DISCUSSION

Identifying and defining problems encountered, as well as their origin and development within the history and evolution of the system of delivery of care in Israel, will lead to some suggestions for a possible solution. Maturation of the system, especially education of the junior staff within the hospital system, is still needed to facilitate the hospital-physician relationship.

CONCLUSION

More active participation of the family physician offers added value to patients' management during their hospital stay and is welcomed by them. The full implementation of a system promoting continuity of care requires further attempts at developing suitable models of cooperation between hospital and family physicians.