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.

Too Much Healthcare: The Harmful Combination of Overdiagnosis and Medical Overuse, Told and Untold Stories

Too much healthcare is prevalent, wasteful, and harmful. It consists of two separate phenomena: overdiagnosis and overuse. Overdiagnosis is the labeling of a person with a disease or abnormal condition that would not have caused the person harm if left undiscovered. Individuals derive no clinical benefit from overdiagnosis, although they may experience physical, psychological, or financial harm. It has been found that 15-30%, 20-50%, 0-67%, and 50-90% of people with screen detected breast, prostate, lung, and thyroid cancer, respectively, are overdiagnosed. Since many screening tests have trade-off between benefit and harm, a shared decision-making approach is essential. Incidental findings are very common and may also cause overdiagnosis. Overdiagnosis is recognizable in populations and not at the individual level. However, overuse is recognizable at the level of the individual practitioner. Choosing Wisely, an intervention directed at reducing low value care, now faces the challenge of developing interventions that go beyond recommendations. While some of the drivers of overdiagnosis and overuse are similar, different and parallel strategies are needed in order to reduce them. This is one of the major challenges to our health care system.

Patient's evaluations and expectations of primary care medicine in Israel revisited after two decades - Health Service Research

BACKGROUND

The European Task Force on Patient Evaluations of General Practice's (EUROPEP) internationally-validated questionnaire measures patients' satisfaction with their primary care physicians. A study published in 1999 showed positive evaluations of primary care among patients across Europe and included 1603 Israeli patients. Major changes have taken place during the past 20 years, in Israel's society, in the healthcare system, and particularly in primary care clinics.

OBJECTIVES

The study aims to reevaluate patients' satisfaction with their primary care physicians and care clinics in Israel and compares the results to the 1999 survey.

METHODS

A survey based on the EUROPEP questionnaire was conducted among 1617 people. Data collection was carried out by an internet panel for the Hebrew speaking population and by a phone questionnaire for the Arabic speaking population.

RESULTS

The study's results show a significant reduction in satisfaction. Notably, patients' satisfaction with physicians' support relating to emotional problems and physicians' explanations about referrals and workup plans have dramatically deteriorated.

CONCLUSIONS

The decrease in patients' satisfaction with primary care physicians and clinics found in the current study is concerning and requires recognition and further exploration.

PRACTICE IMPLICATIONS

The results may be used as a baseline for future assessments of trends in patients' satisfaction.

Comparison of antidepressant use between adult populations living in urban and rural communities in Israel

BACKGROUND

Depression and anxiety are among the most prevalent disorders in primary care. City dwelling is commonly cited as a risk factor for mental disorders, but epidemiological evidence for this relationship is inconclusive.

OBJECTIVE

To compare the prevalence of antidepressant use, as a proxy for the level of depressive disorders, between patients in Israeli urban and rural communities.

METHODS

A cross-sectional study, based on data drawn from the registry of the largest health maintenance organization in Israel. The prevalence of antidepressant purchase during 2014 was evaluated for 581291 patients living in urban and rural communities. Data were also collected for potential confounding variables: age, gender, comorbidity, socioeconomic status and being a holocaust survivor.

RESULTS

Results showed higher rates of antidepressant use among patients living in urban (11.8%) compared with rural communities (8.1%; <0.001). A particularly high rate of antidepressant use was found on kibbutz (15.9%), a collective rural community in Israel, compared with both urban and other rural communities. Kibbutz compared with other rural communities: odds ratio (OR) = 1.73, P < 0.001; urban communities compared with non-kibbutz rural communities: OR = 1.21, P < 0.001. A significantly lower rate of antidepressant use was found in urban and rural Arab-majority communities (3.9% and 3.8%, respectively).

CONCLUSIONS

Antidepressant use varies significantly between different communities in Israel. The highest rate of antidepressant use in our study was found on kibbutz, followed by that in urban communities, with the lowest rates in non-kibbutz rural communities. This difference may derive from different depression rates, stigma of mental illness and awareness of mental disorders.

Illness in context and families as teachers: a year-long project for medical students

The authors describe a program for second-year students in Tel Aviv University's six-year medical school. The program's aim is to teach students the importance of context and interactions in patient care by exposing them to a real patient-family-doctor interaction using narrative-based methods to encourage reflective learning. Each student meets five times a year with a volunteer family, one of whose members suffers from a chronic disease. The program endorses a "patients as teachers" approach, as families are considered to be teachers for the students and not as objects of investigation and assessment. The students receive supervision in small groups, to enhance learning and reflection. To appraise the extent to which students had obtained the required knowledge, skills, and attitudes, the authors extracted reflections regarding the learning experience from students' essays. Major themes identified were becoming "family sensitive," building and improving communication skills, questioning intrusiveness, adopting a nonpatronizing and nonjudgmental attitude, developing reflective skills, creating a future professional model, and experiencing and appreciating continuity of care. The authors argue that learning to listen to patients' narratives, developing a reflective attitude, and being sensitive to patient-family-doctor interactions are of value to all doctors, and therefore programs similar to theirs should be established as part of general medical school education and not just in the context of family medicine.

Orofacial pain and numb chin syndrome as the presenting symptoms of a metastatic prostate cancer

We describe a patient with orofacial pain as the presenting symptom caused by a mandibular metastasis from a previously undiagnosed cancer of the prostate. This possibility should be considered in the differential diagnosis of male patients presenting with orofacial pain.

Use of complementary and alternative medicine among primary care patients

OBJECTIVE

Complementary and alternative medicine use is increasing worldwide, and the expenses are high while its effectiveness is still in debate. The aim of this survey was to evaluate the utilization of complementary and alternative medicine in Israel.

METHOD

Four-hundred and eighty patients in two primary care clinics have participated in the survey and answered an anonymous questionnaire.

RESULTS

Ninety patients (18.7%) have consulted an alternative medicine therapist at least once in the past. Both younger (0-19) and older (65 and older) age groups were associated with a low rate of complementary and alternative medicine utilization. In the adult population, an academic education was associated with a higher utilization rate. The most frequently used methods were homeopathy (34.6%) and reflexology (18.7 %). Musculo-skeletal (20.6%) and respiratory (15.9%) complaints were the most frequent causes for complementary and alternative medicine consultation. The subjective outcome of complementary and alternative medicine treatment was considered beneficial in almost half of the cases and partially beneficial in another 34.6%.

CONCLUSIONS

Utilization of complementary and alternative medicine is as widespread in Israel as in other Western countries. Utilization rates were found to be associated with age and education but not with gender or origin.

Procedure for development of an enzyme-linked immunosorbent assay. Development of an assay for human apolipoprotein A-I

A set of criteria for selection of antibodies during the development of enzyme-linked immunosorbent assay (ELISA) is described. Using these criteria, a competitive ELISA for human apo A-I using a polyclonal goat antibody was developed. The assay recognizes apo A-I from plasma and high-density lipoprotein (HDL), as well as the pure delipidated apo A-I, equally. Intra- and inter-assay variations were 5.2% and 3.5%, respectively. Recovery rate, as determined by spiking a known quantity of pure delipidated apo A-I into a reference plasma, was determined to be 101.3%. The assay was validated by comparing the concentration of apo A-I in HDL with the dye elution method. The apo A-I ELISA to apo A-I dye elution ratio was 1.01. Apo A-I concentration in Centers for Disease Control reference material determined by this method was in agreement with the reported consensus value. Repeated freezing and thawing of the samples (three freeze-thaw cycles at -20 degrees C) as well as long-term freezing (up to 1 year at -70 degrees C) did not affect the concentration of apo A-I in the samples. The assay was applicable both to normolipidemic and dyslipidemic plasmas. No immunologic difference was noted when plasma from dyslipidemic subjects was assayed. A frequent problem of long-term storage is deamidation. The values found for apo A-I in a deamidated plasma were the same as those for the corresponding fresh plasma. Plasma apo A-I values were also positively correlated with that of HDL-cholesterol.(ABSTRACT TRUNCATED AT 250 WORDS)

Platelet activating factor antagonists interact with GABAA receptors

Platelet activating factor (PAF) is ubiquitous in mammals, and may have multiple functions in the central nervous system. Triazolobenzodiazepine compounds are active both at the GABAA receptor and as PAF antagonists. To investigate whether PAF antagonist activity is involved in the actions of triazolobenzodiazepines, we examined effects of two non-benzodiazepine PAF antagonists on binding and function at the GABAA receptor. The gingkolide terpene, BN 52021 and the dioxolane-based compound BN 52115 had no effect on benzodiazepine binding or chloride channel binding in cortical membrane preparations. However, chloride uptake into cortical synaptoneurosomes was enhanced with 1 microM BN 52021 but not 1 microM BN 52115. The effect of BN 52021 was prevented by 1 microM flumazenil. PAF antagonists appear to augment GABAA receptor function without affecting binding.

Kinetic and dynamic components of increased benzodiazepine sensitivity in aging animals

Male CD-1 mice (age 6 weeks, 6 months, 1 and 2 years) received single 2-mg/kg i.p. doses of clonazepam. Plasma and cortex clonazepam concentrations, rotarod ataxia and in vivo benzodiazepine receptor occupancy were measured at multiple times up to 14 hr after dosage. Elimination of clonazepam from plasma and cortex became slower with age, but cortex concentrations always exceeded those in plasma. The mean ratio was 1.82, and was not influenced by age. Rotarod ataxia was quantitatively greater and of longer duration in aging animals. This was not explained entirely by kinetic changes, as ataxia at any given cortex clonazepam concentration or degree of receptor occupancy was greater in 1-year-old animals than in those age 6 weeks or 6 months. In a second study, 6-week and 1-year-old animals were tested at a fixed time (1 hr) after variable doses of clonazepam (0.01-2.0 mg/kg); findings were consistent with results from the fixed-dose study. In vitro studies evaluated benzodiazepine receptor binding, chloride channel binding and muscimol-stimulated chloride uptake in cortical membrane preparations from animals of the four age groups. Binding affinity and number of binding sites were not influenced by age, or was gamma-aminobutyric acid-dependent muscimol-stimulated chloride uptake (either with or without addition of lorazepam) significantly related to age. Thus, increased overall sensitivity of aging animals to the central depressant effects of clonazepam is evident in the described model.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic benzodiazepine administration. III. Upregulation of gamma-aminobutyric acidA receptor binding and function associated with chronic benzodiazepine antagonist administration

Chronic administration of a benzodiazepine agonist appears to downregulate benzodiazepine receptors and gamma-aminobutyric acid (GABA) receptor function. To examine the effects of chronic treatment with a benzodiazepine antagonist, we administered Ro15-1788, 1, 2 and 5 mg/kg/day to mice via implanted s.c. osmotic pumps for 1 to 14 days. Plasma and cortex (CX) concentrations of Ro15-1788 remained constant between days 1 and 7, indicating no change in pharmacokinetics. Open-field activity studies showed no change in distance traveled or ambulatory time at days 1, 2 and 4, but an increase in both parameters at days 7 and 14 in mice receiving Ro15-1788, 2 mg/kg/day. Benzodiazepine receptor binding was unchanged in CX, cerebellum (CB), hypothalamus, hippocampus and ponsmedulla at 1, 2 and 4 days at a dose of 2 mg/kg/day. Binding was increased in CX, CB and hippocampus at day 7 compared to days 1 and 2, and remained elevated at day 14. Similar results were observed at Ro15-1788 doses of 1 and 5 mg/kg/day. Benzodiazepine binding assessed in vitro in CX and CB also was increased at day 7 compared to day 1, due to an increase in receptor number rather than a change in apparent affinity. Binding of t-[35S]butylbicyclophosphorothionate to the chloride channel site in CX after Ro15-1788, 2 mg/kg/day, was increased at days 7 and 14 compared to days 1, 2 and 4 and controls due to an increase in number of binding sites. t-Butylbicyclophosphorothionate binding in CB was unchanged throughout.(ABSTRACT TRUNCATED AT 250 WORDS)

Lorazepam administration during embryonic development alters GABAA receptor binding and function

Prenatal exposure to diazepam has been reported to lead to behavioral alterations in young and mature animals, but the neurochemical basis of this effect is uncertain. To examine effects of embryonic benzodiazepine exposure on the gamma-aminobutyric acidergic (GABA)ergic) system, we assessed binding and function at the GABAA receptor complex in chick embryos treated with lorazepam, 2 mg/kg, for 2-10 days. There was no change in benzodiazepine receptor binding in cortex after lorazepam administration, but a decrease in the number of chloride channel sites was observed. Overall function at the GABAA receptor complex as assessed by chloride uptake into cortical synaptoneurosomes was decreased after 10 days of lorazepam, and possibly increased after 4 days of lorazepam. Similar results were obtained when embryos were treated for 2- and 4-day periods beginning on day 8. These results indicate that chronic lorazepam administration to embryos alters binding and function in the GABA system measured soon before hatching. These alterations, if persistent, may contribute to the behavioral changes seen in animals exposed prenatally.

Structural specificity of MIF-1 and Tyr-MIF-1 in augmenting GABA-stimulated benzodiazepine receptor binding

The possibility of a linkage between endogenous peptides and the GABA-benzodiazepine system has been greatly strengthened by reports that the brain peptides MIF-1(Pro-Leu-Gly-NH2) and Tyr-MIF-1(Tyr-Pro-Leu-Gly-NH2) augment GABA-stimulated benzodiazepine binding. We evaluated the actions of fragments and analogs of these small peptides on GABA-stimulated benzodiazepine binding in mouse cortical brain membranes. Fragments of Tyr-MIF-1, several compounds related to MIF-1, or several analogs of Tyr-MIF-1 had no effect on binding. These results demonstrate the specificity of the effects of MIF-1 and Tyr-MIF-1 on GABA-stimulated benzodiazepine binding.