Michael A. Weingarten

A pilot study of the multidisciplinary management of childhood asthma in a family practice.

A small, controlled trial of joint treatment of childhood asthma by a doctor, a physiotherapist, a psychologist, and a social worker, working together in the family setting, demonstrated an improvement in ventilatory capacity. The limited scope of this trial does not permit more general conclusions as to the effect of such treatment on the severity and frequency of attacks, but the observation that some measurable physiological improvement occurred suggests that the place of multidisciplinary nonpharmaceutical management of childhood asthma should be investigated in more detail.

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 Universitys six-year medical school. The programs 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.

The influence of SCUD missile attacks on the utilization of ambulatory services in a family practice

The consulting load in a family practice exposed to SCUD missile attacks during the 1991 Gulf War was compared with the equivalent period in 1990. The rate of visits was cut by half, with a relative and absolute increase in psychological consultations, and a decrease in consultations for infectious and respiratory conditions. There were more urgent consultations and fewer planned appointments. It is suggested that the stress of the SCUD missile attacks led to a reduction in consultations for trivial disorders, but an increase in the anxiety level of the population.

Medical cultures in collision: primary care of Soviet immigrants in Israel

In Israel immigrant absorption is part of the national ideology. Family doctors cannot look at some patients as belonging and at others as aliens, but must make every effort to understand the culture of each immigrant group as they arrive. This is equally true for the North Africans, the Iraqis, the European Holocaust survivors, the Persians, and the Yemenites, to mention just some of the larger groups.1,2 Despite being such a multicultural society, it is the Anglo-American tradition that most strongly influences modern Israeli medicine. For many of the new immigrant groups this is an unfamiliar environment. The 1990s brought to Israel, a country of under five million, almost half a million new citizens from the former Soviet Union. In this article we follow the recent immigrants from Russia to Israel in the process of their absorption into their new health-care system. Although these immigrants decided to move to Israel for many different reasons, whether they be financial, medical, religious, national ...

The ethics of basing community prevention in general practice

In this paper we argue that the responsibility for systematic community-based preventive medicine should not be made part of the role of the general practitioner (GP). Preventive medicine cannot be shown to be more effective than curative or supportive medicine. Therefore, the allocation of the large amount of general practice staff time and resources required for systematic preventive medicine should not come at the expense of the care of the sick and the suffering. The traditional healing role of the GP requires a cooperative patient-centred approach, whereas systematic preventive medicine is driven by rigid pre-set protocols and is intrinsically paternalistic. Trying to merge the two approaches is detrimental to the doctor-patient relationship. Furthermore, a number of potential pitfalls are identified that may be encountered in the implementation of preventive medicine programmes in general practice: interference with the course of the consultation; inadequate explanation and consent; distortion of practice priorities as reflected in quality indicators; temptation to record inaccurate data; conflict of interests where the doctor is rewarded for performance; patient blaming; exacerbation of the health gap. We suggest that a more justifiable strategy would be for GPs to identify patients at high risk and offer them specific preventive advice when the opportunity presents itself and at a time when the patient is likely to be most amenable to cooperate. Opportunistic health promotion offers higher expectations of benefit, as well as a more equitable allocation of the risks associated with preventive medicine, than a systematic community-based approach.

The current state of basic medical education in Israel: Implications for a new medical school

The recent government decision to establish a new medical school, the fifth in Israel, is an opportune moment to reflect on the state of Basic Medical Education (BME) in the country and globally. It provides a rare opportunity for planning an educational agenda tailored to local needs. This article moves from a description of the context of Israeli health care and the medical education system to a short overview of two existing Israeli medical schools where reforms have recently taken place. This is followed by an assessment of Israeli BME and an effort to use the insights from this assessment to inform the fifth medical school blueprint. The fifth medical school presents an opportunity for further curricular reforms and educational innovations. Reforms and innovations include: fostering self-directed professional development methods; emphasis on teaching in the community; use of appropriate educational technology; an emphasis on patient safety and simulation training; promoting the humanities in medicine; and finally the accountability to the community that the graduates will serve.

Consultations with rabbis.

Objective: To explore the reasons for and the content of consultations between patients and the clergy on medical matters. Setting: four general practices in central Israel. Design: exploratory descriptive study of 42 patients who had consulted rabbis. They were asked about what they expected from the consultation, what happened and with what effect. Results: 90% of consultations were with rabbis who had earned a special reputation for dealing with medical problems, rather than with a local community rabbi. Reproductive problems, psychiatric, and general surgical problems accounted for the majority of consultations. Most patients went to the rabbi for advice or direction; 25% went for a blessing. In general it was recommended that they change doctors, even when this was not the advice they expected. Only rarely was there any contact between the rabbi and the doctor. In over half the cases the idea of consulting the rabbi came from family or friends rather than from the patients. Being actively religious did not seem to be a necessary characteristic of patients who consulted rabbis. Conclusions: Rabbis in a medical role do not seem to practise faith healing as such, but rather act to strengthen a patients faith in the treatment. The medical system does not always succeed in engendering this faith, either in the patient or in the family.

Normal Fluctuations of Leucocyte Counts and the Response to Infection in Benign Familial Leucopenia

In a long-term follow-up of 47 Yemenite patients with benign familial leucopenia, the mean white-cell count was 4,578 with a standard deviation of 940. During bacterial infections, the average leucocyte increment was the same in leucopenic as in non-leucopenic subjects, leading to total leucocyte counts in the normal range in previously leucopenic subjects. The marked degree of variability makes clinical interpretation difficult when leucocyte counts are found between levels standardised as normal in sick patients previously known to be leucopenic.

Schizophrenia in a Yemenite immigrant town in Israel.

A high prevalence of schizophrenia was noted in an Israeli Yemenite immigrant town. In order to throw light on the aetiology all the schizophrenic patients in the care of one family doctor were investigated with respect to various social factors--age at diagnosis, interval since immigration, family status, geographic area of origin. In a practice population of 1185 adults, thirty schizophrenic patients were identified (2.5%). The patients fall into two groups--those diagnosed at a relatively advanced age, born in the Yemen, and parents to an adolescent child; and those Israeli-born diagnosed at the younger age more typical of the disease. The social history of this immigrant community is described and a correlation is suggested between their socio-cultural disintegration and schizophreniform breakdown in the parental generation.

Patients Changing their Family Doctor — The Doctor's Reaction

Objective: Patients who change their family doctor without changing their address call into question the adequacy of the service they have been receiving. In this study, patients were asked to state their reasons when requesting a change of doctor. The doctors were asked what they thought the reason was and how they felt about the patients decision to leave their care. The new doctors chosen by the patients were also asked to describe their reactions to their new patients.Setting: A suburban health centre with seven doctors and 11,500 patients.Methods: Consecutive patients who requested a change of doctor over a six month period completed a written questionnaire. The questionnaires were presented for discussion at weekly practice meetings, the patients stated reason for moving being revealed only after the doctors had expressed their opinions and feelings.Results: 61 individual and family requests were recorded, relating to 109 patients, comprising 0.9% of the practice population. 30% of requests were f...