Andre Matalon

The role of the staff meeting in resolving professional dilemmas in family medicine: concealing a diagnosis

Staff meetings are an integral part of the family medicine process but little has been written in the family medicine literature about their utility. In addition to fining administrative or management functions, the staff meeting can be a creative process for growth of staff members and the road to innovative solutions to clinical problems. Presentation of illness narratives is common in staff meetings. This report describes a staff meeting where a difficult doctor-patient narrative was presented by the treating physician. Contributions from all the doctors in the clinic at the meeting led to improved understanding of the problem and a shared sense of wellbeing.

Family Physicians Leaving Their Clinic— The Balint Group as an Opportunity to Say Good-bye

The cornerstone of family medicine is the belief in both the continuity and availability of care. These beliefs are challenged when a doctor leaves his or her clinic because of personal reasons. In the example described in this article, the involvement of colleagues in a Balint group led a doctor to a flash insight into her conflicting feelings related to leaving her clinic. The group process helped her to prepare and deal with her own feelings and needs, as well as those of her patients and staff. Balint groups are a secure place to explore and gain insight into the emotional aspects of attachment and separation of physicians from their patients.

Non-specific symptoms as clues to changes in emotional well-being

Background -Somatic symptoms are a common reason for visits to the family physician. The aim of this study was to examine the relation between non-specific symptoms and changes in emotional well-being and the degree to which the physician considers the possibility of mental distress when faced with such patients.Methods -Patients who complained of two or more symptoms including headache, dizziness, fatigue or weakness, palpitations and sleep disorders over one year were identified from the medical records of a random sample of 45 primary care physicians. A control group matched for gender and age was selected from the same population. Emotional well-being was assessed using the MOS-SF 36 in both groups.Results -The study group and the control group each contained 110 patients. Completed MOS questionnaires were obtained from 92 patients, 48 patients with somatic symptoms and 44 controls. Sixty percent of the patients with somatic symptoms experienced decreased emotional well being compared to 25% in the control group (p = 0.00005). Symptoms of dizziness, fatigue and sleep disturbances were significantly linked with mental health impairments. Primary care physicians identified only 6 of 29 patients (21%) whose responses revealed functional limitations due to emotional problems as suffering from an emotional disorder and only 6 of 23 patients (26%) with a lack of emotional well being were diagnosed with an emotional disorder.Conclusions -Non-specific somatic symptoms may be clues to changes in emotional well-being. Improved recognition and recording of mental distress among patients who complain of these symptoms may enable better follow up and treatment.

A Cross-Cultural Analysis of Physician Management of Obesity. Comparing the US, France, Israel and Japan: Little Interest and Little Success

Background: Obesity is a global health problem. Physicians are frequently engaged with overweight and obese patients. Obesity guidelines have been successfully implemented on a small scale, but generally physicians struggle to manage obesity effectively. Methods: In a web-based survey, primary care physicians in the United States (US), France, Israel and Japan, were asked how they manage cardiovascular risk factors. They were specifically asked how frequently they saw patients in follow-up for hypertension, hyperlipidemia and obesity. Results: Respondents (956) included 656 French, 198 Israeli, 45 Japanese, and 53 US physicians. Follow-up for obesity no sooner than 3 months was recommended, by 73% (US) and 79% (Israeli) physicians, whereas 67% of French and 66% of Japanese physicians recommended more frequent follow-up (3 months or less). Hypertension and hyperlipidemia was managed more aggressively, especially the US, Israel and Japan. Discussion: Obesity is an international concern, with rates increasing everywhere. The prevalence of obesity is high in the US and Israel and much lower in France and Japan. Chronic disease management is most effective with frequent follow-up. US obesity guidelines recommend frequent (often monthly) follow-up visits. US and Israeli physicians do not appear to be aggressive in managing obesity, whereas French and Japanese physicians report more effort to manage obesity. In the US, obesity management is not considered effective and physicians are uncomfortable attempting to manage obesity with their patients. In France especially, physicians have a more social relationship with their patients and seem oriented toward chronic disease management, including greater attention to lifestyle change. Conclusion: Obesity has been medicalized and is a profound problem internationally. The medical care system must address obesity management more effectively. Further studies are needed to understand how physicians manage obesity and new approaches should be promoted to improve the outcomes of obesity management.

Mortality, morbidity and medical resources utilization of patients with schizophrenia: A case-control community-based study

Patients with schizophrenia have higher level of mortality and physical comorbidity compared to control population. However the association to primary-, secondary- and tertiary-medical resources utilization is not clear. We used a retrospective community-based cohort of patients with schizophrenia (n=1389; age 37.53 years, 64.3% males) and, age-, gender-, and socioeconomic status-matched controls (n=4095; age 37.34 years; 64.3% males) who were followed-up for nine years. Mortality rate of patients was almost twice as high as that of matched controls (7% versus 3.8%). Diagnoses of ischemic heart disease and hypertension were more prevalent among controls than patients (8.2% versus 5%, and 21.6% versus 15.8%, respectively). Tertiary medical resources utilization was higher among patients with schizophrenia than control population (mean hospital admissions per year: 0.2 versus 0.12, emergency department visits: 0.48 versus 0.36). Patients that died were more likely to have cardiovascular disease, to be admitted to general hospital and to spend more days in hospital than patients that did not die. There is a discrepancy between lower rates of cardiovascular disease diagnoses but higher rates of mortality and tertiary medical resources utilization among patients with schizophrenia when compared to control population. This may stem from an under-diagnosis and, eventually, under-treatment of these patients.

Validation of the 2016 USPSTF recommendations for primary cardiovascular prevention in a large contemporary cohort

Aims The aim of this study was to evaluate the performance of the US Preventive Services Task Force (USPSTF) cholesterol recommendations in a contemporary non-US cohort. Methods and results This is a historical cohort analysis of electronic records from Israels largest health provider. All patients in the Tel Aviv district eligible for primary cardiovascular prevention were followed between January 2005 and December 2015. Risk was estimated by the pooled cohort equations. Statin eligibility was determined by USPSTF and American College of Cardiology and American Heart Association (ACC/AHA) recommendations. Atherosclerotic cardiovascular disease events were retrieved from electronic registration. The mean ± standard deviation age of the 10,889 (98,258 person-years) participants was 60.3 ± 9.4 years, and 69.1% were women. Outcome events were recorded for 1351 patients (12.4%). Treatment recommendations were discordant in 901 patients (8.3%) whose treatment was indicated only by the ACC/AHA guidelines, implying a 26% reduction in newly eligible patients for statin treatment had the USPSTF recommendations been implemented. Among the statin-naive patients, the pooled cohort equations underestimated the risk, with a predicted-to-observed event ratio of 0.88. The recommended treatment thresholds provided excellent calibration, with ratios of 1.0 for USPSTF and 0.98 for ACC/AHA-eligible patients. Both models showed similar discrimination (Harrels C = 0.63 (0.62–0.65) for USPSTF vs. 0.64 (0.63–0.66) for ACC/AHA, P = 0.26). The USPSTF recommendations were less sensitive and more specific for the detection of outcome events than the ACC/AHA recommendations (61% vs. 75% and 68% vs. 55%, respectively). The net reclassification index was −0.01. Conclusions Calibration, discrimination and net reclassifications were very similar for USPSTF and ACC/AHA recommendations. Applying the USPSTF recommendations could reduce over-treatment.

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.