Avraham Friedman, MD and Amnon Lahad, MD, MPH
Background: Alternative medicine use is increasing worldwide and the associated expenditures are significant. In Israel 19% of patients who consulted their family physician had also sought treatment by an alternative medicine practitioner.
Objectives: To explore the correlation between different modalities of healthcare utilization, health behavior, and health belief among adult members of a kibbutz. This unique study population enabled the use of a simplified quantitative model due to the minimal individual differences in cost and access.
Methods: Healthcare utilization data were obtained for 220 kibbutz members aged 15–70 years from patient medical files and self-administered questionnaires over a 45 month period. Patient visits to the family practitioner and other specialist physicians were tallied, and individuals reported alternative medicine consultations during the previous year. Multiple regression analysis was used to control for age, chronic disease, and other background characteristics.
Results: The mean number of patient FP visits was 3.6 per patient per year. Women and chronic disease sufferers visited the doctor more frequently. A patient’s number of FP visits and other specialist physician visits were closely correlated, with each specialist physician consult resulting in an additional 0.64 FP visit for a given individual (P=0.007). Our analysis indicated that self-reported alternative therapy utilization was positively associated with the number of FP visits; patients reporting alternative therapy use visited their primary care physician once additionally per year (P=0.03). Low self-rated health status was correlated with increased likelihood of alternative therapy use (borderline significance).
Conclusion: These results suggest that a patient who seeks treatment from one type of healthcare practitioner will seek out other practitioners as well. This study supports the notion that unconventional therapies are used in conjunction with, rather than instead of, mainstream medical care.
Shlomo M. Monnickendam MD, Shlomo Vinker MD, Simon Zalewski MD, Orli Cohen MD and Eliezer Kitai MD, and Research Group of the Department of Family Medicine, Tel Aviv University
Background: Patients’ consent to being part of medical education is often taken for granted, both in primary and secondary care. Formal consent procedures are not used routinely during teaching and patients are not always aware of teaching activities.
Objective: To investigate patients’ attitudes and expectations on issues of consent regarding participation in teaching in general practice, and the influence of a student’s presence on the consultation.
Methods: The study took place in 46 teaching practices during the sixth year clinical internship in family medicine. Patients completed questionnaires at the end of 10 consecutive eligible consultations. The questionnaire contained data on the willingness to participate in teaching, the preferred consent procedure and the effects of the student’s presence. The doctors were asked to estimate the sociodemographic level in their clinic area.
Results: A total of 375 questionnaires were returned; the response rate was not affected by the clinic’s sociodemographic level. Overall, 67% of the patients had come into contact with students in the past; 3.2% of the participants objected to the presence of a student during the consultation; 15% would insist on advance notification of the presence of a student, and another 13.9% would request it; 4% stated that the presence of students had a detrimental influence on the physical examination and history; and 33.6% would refuse to be examined by a student without the doctor’s presence.
Conclusion: Most patients agreed to have a student present during the consultation; some would like prior notification; a minority refused the student’s presence. A large minority would refuse to be examined without the tutor’s presence. Our findings need to be taken into account when planning clinical clerkships.
Sasson Nakar MD, Shlomo Vinker MD, Eliezer Kitai MD, Eli Wertman MD and Michael Weingarten MD
Background: Migration leads to changes in almost all areas of life including health. But how far are health beliefs also preserved, and how far are they affected by the process of acculturation to the host society?
Objectives: To examine the difference between behavior and attitudes towards conventional and traditional medicine among elderly Yemenite immigrants.
Methods: A community-based study was conducted in the Yemenite neighborhoods in the city of Rehovot. All inhabitants of Yemenite origin over the age of 70 were identified from the population register, excluding those who were institutionalized or demented. Social work students interviewed them at home. The questionnaire inquired after health problems in the preceding month. For each of these problems, the respondent was asked whether any mode of treatment had been employed – Yemenite folk remedies, conventional medical care, or other. Their attitudes towards Yemenite folk medicine and conventional medicine were recorded. Socioeconomic data included their current age, age at immigration, year of immigration, marital status, gender, religiosity, and education.
Results: A total of 326 elderly people were identified who fulfilled the selection criteria, of whom 304 (93%) agreed to be interviewed. Of these, 276 (91%) reported at least one health problem in the preceding month, providing 515 problems of which 349 (68%) were reported to a conventional medical doctor while 144 (28%) were treated by popular folk remedies. Fifty-nine problems (11.5%) were treated by specifically Yemenite traditional remedies, mostly by the respondents themselves (38/59) rather than by a traditional healer. Immigrants who arrived in Israel over the age of 30 years, as compared to respondents who immigrated at an earlier age and grew up in Israel, were more likely to use traditional Yemenite remedies (24.4% vs. 8.2%, P<0.005).
Conclusion: Aged Yemenite Jews in Israel prefer modern medicine. The earlier the immigrant arrived in Israel, the more positive the attitude towards modern medicine and the less use made of traditional Yemenite healing.
John Yaphe MD MClSc, Moshe Schein MB ChB MS and Pnina Naveh RN
Background: The recent influx of Ethiopian immigrants to Israel has created challenges for healthcare workers. Qualitative research methods have proven to be of value in providing useful data in cross-cultural medical settings.
Objective: To learn about parents' perception of the health of their children among a group of Ethiopian immigrants in Israel.
Methods: Ethiopian parents of children under age 3 registered with a family medicine clinic in Jerusalem were invited to participate in two focus groups. Transcripts of the group discussions were analyzed to reveal themes relating to children's health.
Results: Analysis of the transcripts revealed five themes relating to the health of children in two domains: the intra-familial and the extra-familial. Specific themes that emerged in the intra-familial domain were: the role of traditional medicine, gender-specific roles in child care, and decision-making in seeking extra-familial medical help. Themes in the extra-familial domain were recognition of illness and the meaning of symptoms, and notions of prevention and resistance to illness. The collected data found application in the daily clinical work of the researchers and enriched understanding of their patients.
Conclusions: Ethiopian immigrants to Israel share special perceptions of their children’s health that differ from prevailing beliefs in Israel. Focus groups provide health workers with a wealth of data on these beliefs that will enable them to offer more culturally sensitive care.
Howard Tandeter MD, Mirta Grynbaum MD and Jeffrey Borkan MD PhD
Background: Bloodletting is practiced in Ethiopia. Physicians in Israel engaging in transcultural encounters with Ethiopian immigrants are generally unaware of these ethnomedical beliefs and practices.
Objective: To assess the past and present use of bloodletting among Ethiopian immigrants in Israel.
Methods: We interviewed a sample of 50 adult patients of Ethiopian origin about present and past use of bloodletting. A second consecutive sample of 10 adult patients of Ethiopian origin who often asked their doctors to perform blood tests were identified and interviewed. Data analysis was performed by "immersion-crystallization" analysis.
Results: More than half of the interviewed patients reported the use of bloodletting. Scars were commonly present on their upper extremities. A qualitative analysis identified the different reasons for the use of bloodletting, the technique used and its appreciated efficacy. We also found an unexpected cultural synergy between traditional bloodletting and western medical blood sampling.
Conclusions: Some Ethiopian immigrants continue to perform traditional bloodletting in their new country of residency, a practice that local physicians may not be aware of. Bloodletting-type scars on the upper extremities may be common in these patients. Patients may ask for blood sampling as a culturally accepted way to perform bloodletting (synergy).
Rachel Dahan, MD, Shmuel Reis, MD, Doron Hermoni, MD and Jeffrey Borkan, MD
Rachel Dahan, MD, Shmuel Reis, MD, Doron Hermoni, MD and Jeffrey Borkan, MD
Howard Tandeter, MD and Martine Granek-Catarivas, MD
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 prinary 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 university towards family medicine may negatively affect the number of students going into this specialty. Examples from Israeli faculties are presented.
Shmuel Reis MD, Margalit Goldfracht MD, Ada Tamir DSc, Riki Van Raalte MA, Tomas Spenser FRCGP and Doron Hermoni MD
Background: Which medical specialties do Israeli medical graduates choose? Answers to this question can serve as an essential means of evaluating both Israeli medical education and the healthcare system.
Objectives: To determine the distribution of medical specialty choice, its change over time and the posible influence of the medical school on the choice; to study the graduates’ gender, gender variability in specialty choice of family medicine as a career among the graduates as a group, by medical school, gender, and time trends.
Method: The study population comprised all graduates of the four medical schools in Israel during 16 years: 1980-1995 inclusive. Data were obtained from the four medical schools, the Israel Medical Association’s Scientific Council, and the Ministry of Health. Data allowed for correct identification of two-third of the graduates.
Results: A total of 4,578 physicians graduated during this period. There was a significant growth trend in the proportion of women graduates from 22.6% in 1980 (lowest: 20.0% un 1981) to 35.3 in 1995 (highest: 41.5% in 1991). Overall, 3,063 physicians (66.8%) started residency and 1,714 (37.4%) became specialists. The four most popular residencies were internal medicine. Ten percent of Israeli graduates choose family medicine.
Conclusions: The overall class size in Israel was stable at a time considerable population change. Women’s place in Israeli medicine is undergoing significant change. Family medicine is one of the four most popular residencies. Amonitoring system for MSC in Israel is imperative.
Uzi Milman MD, Mordechai Alperin MD, Shmuel Reis MD, Riki Van-Ralte MA and Doron Hermoni MD BSc
Background: Most of the published documents proposing teaching objectives for undergraduate clerkships were prepared by expert bodies. Seldom have the clinical teachers, who are critical to the learning process and to the implementationof the teaching objectives, been the actual proponents of its core content.
Objective: To develop a national-scale proposal of teaching, objectives for the family medicine clerckship in medical school, using a consensus method and the actual, community-based teachers as the expert body.
Method: The Delphi method was chosen for that purpose. In the first round all 189 family medicine teachers in Israeli medical schools were asked to propose five teaching objectives. In the second round the objectives, which were generatedin the first round, were characterized by key words and were send to the participants as a second round for ranking according to their importance.
Results: A total of 116 family medicine teachers (61.38%) responded in the first round and 91 of the 116 (78.5%) in the second round. They formulated 51 teaching objectives listed in order of importance, covering a wide array of themes and including knowledge, attitude and skills objectives. The most important objectives were common problems in primary care, recognition of the biopsychosocial model, and understanding the importance of the doctor-patient relationship. The structure of the list provides a uniqe insight into the relative importance of each objective in the context of the whole core content of the clerkship.
Conclusions: Constructing a proposal for teaching objectives is feasible using the Delphi method and the field instructors as the selecting body. The process and its results can provide faculty with relevant and important suggestions on the content and structure of the family medicine clerkship.