Defensive medicine in Israel - a nationwide survey

Background

Defensive medicine is the practice of diagnostic or therapeutic measures conducted primarily as a safeguard against possible malpractice liability. We studied the extent, reasons, and characteristics of defensive medicine in the Israeli health care system.

Methods and Findings

Cross-sectional study performed in the Israeli health care system between April and July 2008 in a sample (7%) of board certified physicians from eight medical disciplines (internal medicine, pediatrics, general surgery, family medicine, obstetrics and gynecology, orthopedic surgery, cardiology, and neurosurgery). A total of 889 physicians (7% of all Israeli board certified specialists) completed the survey. The majority [60%, (95%CI 0·57–0·63)] reported practicing defensive medicine; 40% (95%CI 0·37–0·43) consider every patient as a potential threat for a medical lawsuit; 25% (95%CI 0·22–0·28) have previously been sued at least once during their career. Independent predictors for practicing defensive medicine were surgical specialty [OR = 1.6 (95%CI 1·2–2·2), p = 0·0004], not performing a fellowship abroad [OR = 1·5 (95%CI 1·1–2), p = 0·027], and previous exposure to lawsuits [OR = 2·4 (95%CI 1·7–3·4), p<0·0001]. Independent predictors for the risk of being sued during a physician''s career were male gender [OR = 1·6 (95%CI 1·1–2·2), p = 0·012] and surgery specialty [OR = 3·2 (95%CI 2·4–4·3), p<0·0001] (general surgery, obstetrics and gynecology, orthopedic surgery, and neurosurgery).

Conclusions

Defensive medicine is very prevalent in daily physician practice in all medical disciplines. It exposes patients to complications due to unnecessary tests and procedures, affects quality of care and costs, and undermines doctor-patient relationships. Further studies are needed to understand how to minimize defensive medicine resulting from an increased malpractice liability market.     

Prevalence of obese patients in a primary care setting

Objective: Previous research has addressed the relationship between BMI and chronic disease in primary care; however, little has been done with regard to the association between obesity and depression in primary care. The purpose of this paper is to assess the relationship between obesity and chronic conditions including depression. Research Methods and Procedures : Data from primary care patients seen at a university‐based family medicine clinic in the southeastern United States were extracted for the time between January 1, 1999 and January 1, 2002. Data extracted included most recent height and weight, age, ethnicity, pregnancy status, number of office visits, blood pressure, cholesterol, hemoglobin A_1C, current diagnoses, and medications. Results : A total of 8197 patients were included in the analysis. Sixty‐nine percent of patients seen in a 3‐year period were either overweight or obese. Comparing blood pressure, cholesterol, diagnoses, and medications between BMI groups found differences in virtually all categories. Diagnoses of high cholesterol, hypertension, diabetes, and depression significantly increased for obese patients. Discussion : Obese patients are over‐represented in primary care, and this over‐representation of obesity correlates with several diagnoses, including depression. Depression is a chronic disease that may interfere with health‐related behaviors and must be addressed within the health care system.     

Consultation patterns and clinical correlates of consultation in a tertiary care setting

Background

Chronic diarrhoea is one of the most debilitating consequences of HIV infection in sub-Saharan Africa and it carries a high mortality rate. We report unexpectedly low concentrations of circulating aldosterone in 12 patients (6 men, 6 women) in the University Teaching Hospital, Lusaka, who all had diarrhoea for over one month. Changes in serum electrolytes, blood pressure, Karnofsky score and serum aldosterone concentration were being monitored during a short study of responses to saline infusion (3 litres/24 h) over 72 hours.

Findings

At baseline, 9/12 (75%) of the patients were hyponatraemic, 10/11 (91%) were hypokalaemic, and 6/12 (50%) had undetectable aldosterone concentrations. Blood pressure and Karnofsky score rose and creatinine concentration fell in response to the infusion.

Conclusion

Circulating aldosterone concentrations were inappropriately low and complicate the profound electrolyte deficiencies resulting from chronic diarrhoea. Management of these deficiencies needs to be more aggressive than is currently practised and consideration should be given to a formal clinical trial of mineralocorticoid replacement in these severely ill patients. If the inappropriately low aldosterone reflects a general adrenal failure, it may explain a considerable proportion of the high mortality seen both before and after initiation of anti-retroviral therapy.     

Sex and gender medicine in physician clinical training: results of a large,single-center survey

Background

“Sex and Gender Medicine” is a novel medical discipline that takes into account the effects of sex and gender on the health of women and men. The Institute of Medicine in the USA declared in its 2001 and 2010 statements that being a woman or a man significantly impacts the course of diseases, and therefore, this fact must be considered in diagnosis and therapy. We evaluated the representation of Sex and Gender Medicine in clinical training at Cedars-Sinai Medical Center, a large, tertiary, non-profit, academic medical training center in the Western United States.

Methods

Post-graduate physician trainees (residents and fellows) in all medical and surgical departments (medicine, surgery, OB-GYN, pediatrics, anesthesiology, pathology, urology, electrophysiology, pulmonary critical care, cardiology, women’s heart, medical genetics, radiology, neurosurgery, and radiation oncology) were surveyed online; 80 (55 and 45 % female and male residents, respectively) out of 890 physicians (9 % response rate) responded to questions regarding sex and gender-based medicine.

Results

Seventy percent of post-graduate physician trainees indicated that gender medicine concepts are never or only sometimes discussed/presented in their training program. Slightly greater than 70 % of the trainees indicated that gender concepts are never or only sometimes incorporated into didactic lectures or clinical teaching. However, more than 65 % felt that gender medicine concepts are important, and 60 % agreed that gender medicine curriculum should be implemented and taught in their clinical program.

Conclusions

Current physician trainees endorse both a current lack of and need for Sex and Gender Medicine clinical training.

     

Genetic testing and primary care: a new ethic for a new setting

For several decades, clinical geneticists have espoused two key ethical principles, nondirectiveness and confidentiality. These principles made a great deal of sense in the highly personal and controversial setting of reproductive genetics. Now that clinical genetics has entered the primary care setting, clinicians are rethinking the strength of their commitment to these traditional norms and they are revamping their ethical priorities. Patients increasingly need advice about whether they should take genetic tests and whether and how they should respond to the test results. Patients also need to know about how this information will impact family members and whether other members of their family should be tested. Clinical geneticists may even consider breaking individual confidentiality in order to prevent harms to family members. Although clinical geneticists do not need to abandon nondirectiveness and confidentiality in this new setting, they may not strictly adhere to these principles in some circumstances in order to benefit patients and their families.     

Genetic testing and primary care: a new ethic for a new setting

For several decades, clinical geneticists have espoused two key ethical principles, nondirectiveness and confidentiality. These principles made a great deal of sense in the highly personal and controversial setting of reproductive genetics. Now that clinical genetics has entered the primary care setting, clinicians are rethinking the strength of their commitment to these traditional norms and they are revamping their ethical priorities. Patients increasingly need advice about whether they should take genetic tests and whether and how they should respond to the test results. Patients also need to know about how this information will impact family members and whether other members of their family should be tested. Clinical geneticists may even consider breaking individual confidentiality in order to prevent harms to family members. Although clinical geneticists do not need to abandon nondirectiveness and confidentiality in this new setting, they may not strictly adhere to these principles in some circumstances in order to benefit patients and their families.     

Management of alcoholism in the primary care setting.

Primary care physicians can play an important role in managing alcoholic patients. Identifying and treating alcoholism early, before it has interfered with patients'' relationships and work, may increase the likelihood of prolonged recovery. Simple office interventions can help motivate patients to abstain and seek treatment. People who abuse alcohol and are unwilling to abstain can benefit from a recommendation to reduce their intake of alcohol. For alcohol-dependent patients who decide to stop drinking, primary care physicians often can manage withdrawal on an outpatient basis. Selecting an appropriate treatment program for each alcoholic patient is important, and referral to a specialist to assist in matching patients to treatments is often necessary. Primary care physicians also can help prevent relapse. Although disulfiram is of limited value, primary care physicians can support recovery by identifying coexistent psychosocial problems, helping patients to restructure their lives, and ensuring continuity of care.     

The presence of HIV infection in a hospital-based primary care setting

Background: The incidence of HIV infection in the general population continues to grow as a cure is yet to be found. Fortunately, great strides have been made in treating this multifactorial disease so patients are living longer and more productive lives. As a result, there is a growing demand from all health care disciplines, including optometry, to provide care for patients with HIV infection. Methods: From June 1, 1994 through May 30, 1995, HIV seropositive patients presenting to the primary care optometry clinic at the Bascom Palmer Eye Institute were identified from the total clinic population. All patients presented to the clinic as part of a routine eye exam or were referred by a primary physician. All abnormal findings were recorded in a log in addition to the CD4⁺ T-cell count. Results: One hundred and fifty HIV seropositive patients were identified from the clinic population. Fifty percent were ocularly abnormal including 31 patients (20.7%) with HIV microangiopathy, and nine patients (6%) with CMV retinitis. One hundred and eighteen patients (78.7%) knew their CD4 count. There was a correlation between HIV-related ocular findings and low CD4 counts. Similarly 65.6% of the patients who did not know or did not share their CD4 counts had abnormalities in their eye exam with 52.4% being HIV related. Conclusion: Optometrists play an important part of the health care team since patients with HIV infection present to primary care optometrists for comprehensive eye care as demonstrated in this study. The optometrist must be aware of the status of their CD4 count as this helps determine the risk for having HIV-related problems. Many patients will be able to provide this information as shown. Caution must be displayed with patients who do not know their CD4 count as this may be a poor prognostic sign. Finally, optometrists must educate patients about the risk for developing ocular complications from HIV as part of their eye care as both HIV microangiography and CMV retinitis were the most common AIDS-related ocular findings.     

Screening and diagnosis of alcoholism in the primary care setting.

As many as 20% of patients seeing their primary physicians may suffer from alcohol abuse and dependence. Often the problem goes unrecognized. In this article I summarize what is known regarding the natural history, risk factors, and available screening techniques for alcoholism. Ultimately, a diagnosis of alcoholism is based on a patient''s history, and there are various approaches to obtaining a thorough alcohol history and overcoming patient denial regarding an alcohol problem. Primary physicians have an important role in educating patients about alcoholism.     

Need and demand for primary health care: a comparative survey approach.

OBJECTIVE--To develop general practice profiles of needs and demand for primary health care. DESIGN--Postal survey of a stratified random sample of 3478 people registered with five general practices. Data from a single practice were compared with data from the remaining four to identify areas of comparative need. SETTING--Five general practices in Lothian. MAIN OUTCOME MEASURES--Differences between the single practice and the comparison practices in terms of social and economic circumstances, limiting long term illness, specific ongoing conditions, minor illness or symptoms, psychosocial problems, discussion of lifestyle, associated use of services. RESULTS--Respondents from the single practice reported higher rates than those in the four comparison practices of ongoing mental health and respiratory problems and use of antidepressants, tranquillisers, or sleeping tablets. Although rates of limiting long term illness and other specific ongoing conditions were comparable, the rates of minor illness or symptoms and psychosocial difficulties were higher in the single practice. Respondents from the single practice were more likely to consult frequently, to have contacted the practice out of normal working hours, and to have discussed psychosocial difficulties with a general practitioner. For any specific ongoing condition or "minor" illness, respondents from the single practice were no more likely to consult. CONCLUSIONS--A comparative survey approach is a useful method of developing an understanding of patterns of need and demand among general practice populations. It has the potential to inform planning within individual general practices and the process of commissioning among general practices within a given area.     

Portion control for the treatment of obesity in the primary care setting

Background

Marbling defined by the amount and distribution of intramuscular fat, so-called Shimofuri, is an economically important trait of beef cattle in Japan. Our previous study detected 3 single nucleotide polymorphisms (SNPs), g.231054C > T, g.3109537C > T and c.*188G > A, respectively, in the 5' flanking region of the titin (TTN), the 5' flanking region of the ribosomal protein L27a (RPL27A) and the 3' untranslated region of the akirin 2 genes (AKIRIN2), which have been considered as positional functional candidates for the genes responsible for marbling, and showed association of these SNPs with marbling in Japanese Black beef cattle. In the present study, we investigated the allele frequency distribution of the 3 SNPs among the 5 cattle breeds, Japanese Black, Japanese Brown, Japanese Shorthorn, Holstein and Brown Swiss breeds.

Findings

We genotyped the TTN g.231054C > T, RPL27A g.3109537C > T and AKIRIN2 c.*188G > A SNPs by polymerase chain reaction-restriction fragment length polymorphism method, using 101 sires and 1,705 paternal half sib progeny steers from 8 sires for Japanese Black, 86 sires and 27 paternal half sib progeny steers from 3 sires for Japanese Brown, 79 sires and 264 paternal half sib progeny steers from 14 sires for Japanese Shorthorn, 119 unrelated cows for Holstein, and 118 unrelated cows for Brown Swiss breeds. As compared to the frequencies of the g.231054C > T T, g.3109537C > T T and c.*188G > A A alleles, associated with high marbling, in Japanese Black breed that has been subjected to a strong selection for high marbling, those in the breeds, Japanese Shorthorn, Holstein and Brown Swiss breeds, that have not been selected for high marbling were null or lower. The Japanese Brown breed selected slightly for high marbling showed lower frequency than Japanese Black breed in the g.3109537C > T T allele, whereas no differences were detected between the 2 breeds in the frequencies of the g.231054C > T T and c.*188G > A A alleles.

Conclusions

Based on this finding, we hypothesized that the pressure of the strong selection for high marbling in Japanese Black breed has increased the frequencies of the T, T and A alleles at the TTN g.231054C > T, RPL27A g.3109537C > T and AKIRIN2 c.*188G > A SNPs, respectively. This study, together with the previous association studies, suggested that the 3 SNPs may be useful for effective marker-assisted selection to increase the levels of marbling.