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Discusses the regional impact of a U.S. military action against Iraq. Number of Iraq's population that are in exile; Information on federalism; Goal of the U.S. and the new Iraqi government; Opinion on how to protect Iraq's transition to democracy.

Abstract 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.

Abstract Background The prevalence and incidence of asthma are believed to be increasing but research on the true incidence, prevalence and mortality from asthma has met methodological obstacles since it has been difficult to define and diagnose asthma in epidemiological terms. New and widely accepted diagnostic criteria for asthma present opportunities for progress in this field. Studies conducted in Portugal have estimated the disease prevalence between 3% and 15%. Available epidemiological data present a significant variability due to methodological obstacles. Aim To estimate the true prevalence of asthma by gender and age groups in the population of the area covered by one urban Health Centre in Portugal. Method An observational study was conducted between February and July 2009 at the Horizonte Family Health Unit in Matosinhos, Portugal. A random sample of 590 patients, stratified by age and gender was obtained from the practice database of registered patients. Data was collected using a patient questionnaire based on respiratory symptoms and the physician's best knowledge of the patient's asthma status. The prevalence of asthma was calculated by age and gender. Results Data were obtained from 576 patients (97.6% response rate). The mean age for patients with asthma was 27.0 years (95% CI: 20.95 to 33.16). This was lower than the mean age for non-asthmatics but the difference was not statistically significant. Asthma was diagnosed in 59 persons giving a prevalence of 10.24% (95% CI: 8.16 to 12.32). There was no statistically significant difference in the prevalence of asthma by gender. Conclusion The prevalence of asthma found in the present study was higher than that found in some studies, though lower than that found in other studies. Further studies in other regions of Portugal are required to confirm these findings.

Abstract Background Recent surveys show that the knowledge of the general public about the correct use of antibiotics is limited. This contributes to the problem of inappropriate antibiotic use, leading to a progressive loss of bacterial sensitivity to these drugs and the spreading of resistant strains of bacteria. Methods In this cross-sectional study, a questionnaire about antibiotic use was given to a sample of students in the 9th and 12th grades of secondary school and in the first year of university in the north of Portugal. Results 349 students returned completed questionnaires. Deficits were found in the students' knowledge of antibiotics and their correct use. Only 4% of 9th grade students were aware that antibiotics are used to treat bacteria only, while 14% of 12th grade students and 29% of first-year university students were aware of this. Fewer students were aware that antibiotics are used to treat tuberculosis. There were deficiencies in the knowledge of timing and duration of therapy. However close to 70% of these students are aware that inappropriate use of antibiotics can contribute to resistance to these drugs. Conclusion This study has observed a lack of general knowledge on correct antibiotic use in Portugal, as has been found in other countries. Since this may be due to a lack of formal education on this subject, we believe that a teaching unit on infectious diseases should be included in the 9th and 12th grades, in all curricular areas, with emphasis on bacterial and viral pathogens and correct antibiotic use. In addition, education on the correct use of medications may need to begin at much earlier ages.

Abstract Background Somatization is a common problem in primary care and often presents puzzling problems for the family physician. A family or contextual approach is often useful in investigating and treating refractory symptoms. Case presentation A 63 year-old patient presented to his family physician with recurrent episodes of syncope, weakness and various other somatic symptoms. Lengthy clinical investigations found no organic pathological findings but a brief family assessment by the family physician revealed that the patient's wife was the "hidden" patient. Successful treatment of the patient's wife led to full recovery for both. Conclusions Exploration and treatment of the family context may often hold the key to the solution of difficult problems in somatizing patients.

Abstract Background Continuing medical education (CME) for general practitioners relies on specialist-based teaching methods in many settings. Formal lectures by specialists may not meet the learning needs of practitioners and may cause dissatisfaction with traditional CME. Increasing learner involvement in teaching programs may improve learner satisfaction. Methods A quality improvement program for CME for 18 general practitioners in the Tel Aviv region was designed as a result of dissatisfaction with traditional CME activities. A two-step strategy for change was developed. The CME participants first selected the study topics relevant to them from a needs assessment and prepared background material on the topics. In the second step, specialist teachers were invited to answer questions arising from the preparation of selected topics. Satisfaction with the traditional lecture program and the new participatory program were assessed by a questionnaire. The quality criteria included the relevance, importance and applicability of the CME topic chosen to the participant's practice, the clarity of the presentation and the effective use of teaching aids by the lecturer and the potential of the lecturer to serve as a consultant to the participant. Results The participatory model of CME significantly increased satisfaction with relevance, applicability and interest in CME topics compared to the traditional lecture format. Conclusions Increased learner participation in the selection and preparation of CME topics, and increased interaction between CME teachers and learners results in increased satisfaction with teaching programs. Future study of the effect of this model on physician performance is required.

Background: During the COVID-19 pandemic in Ontario, Canada, an Emergency Standard of Care for Major Surge was created to establish a uniform process for the "triage" of finite critical care resources. This proposed departure from usual clinical care highlighted the need for an educational tool to prepare physicians for making and communicating difficult triage decisions. We created a just-in-time, virtual, simulation-based curriculum and evaluated its impact for our group of academic Emergency Physicians., Methods: Our curriculum was developed and evaluated following Stufflebeam's Context-Input-Process-Product model. Our virtual simulation sessions, delivered online using Microsoft Teams, addressed a range of clinical scenarios involving decisions about critical care prioritization (i.e., Triage). Simulation participants completed a pre-course multiple-choice knowledge test and rating scales pertaining to their attitudes about using the Emergency Standard of Care protocol before and 2-4 weeks after participating. Qualitative feedback about the curriculum was solicited through surveys., Results: Nine virtual simulation sessions were delivered over 3 weeks, reaching a total of 47 attending emergency physicians (74% of our active department members). Overall, our intervention led to a 36% (95% CI 22.9-48.3%) improvement in participants' self-rated comfort and attitudes in navigating triage decisions and communicating with patients at the end of life. Scores on the knowledge test improved by 13% (95% CI 0.4-25.6%). 95% of participants provided highly favorable ratings of the course content and similarly indicated that the session was likely or very likely to change their practice. The curriculum has since been adopted at multiple sites around the province., Conclusion: Our novel virtual simulation curriculum facilitated rapid dissemination of the Emergency Standard of Care for Major Surge to our group of Emergency Physicians despite COVID-19-related constraints on gathering. The active learning afforded by this method improved physician confidence and knowledge with these difficult protocols., (© 2022. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Background: Empathy in the patient-physician relationship is a major component in an effective placebo treatment, as in every medical treatment. Understanding the role of empathy of the physician in the placebo effect may help dissect some of the context variables responsible for the effectiveness of the placebo., Objectives: To determine the frequency of placebo prescription, doctors' beliefs, motivation, and attitudes to placebos in general practice in northern Portugal and to test the association between placebo prescription and physician empathy., Methods: A cross-sectional study was conducted between November 2014 and January 2015 among general practice specialists and interns from 14 health centres in a northern Portuguese health region. The self-report questionnaire included the Portuguese version of the Jefferson scale of physician empathy (JSPE) and a questionnaire about placebo prescription. Associations between demographic variables, JSPE score, prescription of placebo, and the attitudes to placebo score were tested with the chi-squared statistic, student t-tests for independent samples, and Pearson correlation., Results: The study included 93 general practitioners (GP) (response rate: 74%). Placebos were prescribed by 73% (n = 68) of the respondents. GPs who prescribe placebo are significantly younger (mean age = 38.4 years; SD = 11.1; t (90) = 2.98, P <.05, d = 0.67) than non-prescribers (mean age =46.5 years; SD =13.3). Favourable attitudes towards placebo prescription are associated with higher empathy scores (R = 0.310, P <.01)., Conclusion: Placebo prescription is frequent and associated with empathy from the prescriber, especially among younger GPs.

The international Bled course for teacher training has played a central role in faculty development in family medicine for the past 25 years. The course was originally designed to promote faculty development for family medicine teachers in the new academic discipline of family medicine in Slovenia in 1990 and to introduce new topics into the family medicine curriculum. In this background paper, we perform a SCOT analysis (strengths, challenges, opportunities, and threats) of the current course, evaluating participant feedback and reviewing past topics and their impact on local and international teaching programmes. We also review the place of the course in the context of other teacher-training programmes in family medicine in Europe. We found that the structure and learning aims of the Bled course have remained stable over 25 years. It provides a safe, well-structured learning environment for the participants even though the course topic is different every year. The course has had a significant impact on curriculum development and teacher training in Slovenia as well as in many other countries in Europe and beyond. Because of the positive impact of the course and the high degree of satisfaction of the participants and course directors, it seems worthwhile to continue this endeavour. New directions for the course will depend on the learning needs of the participants and the evolving medical curricula in the countries they represent.

Background: A research agenda can help to stimulate and guide research. The International Primary Care Respiratory Group (IPCRG) published a Research Needs Statement (RNS) in 2010 in which 145 research questions were identified. In 2012, priorities for respiratory research were established, based on these questions. To date, there has been no statement on primary care respiratory research needs in Portugal. The aim of the study was to develop a national consensus on research priorities in respiratory diseases in primary care in Portugal and to assess the applicability of the priorities for respiratory research set by the IPCRG., Method: We conducted a Delphi study by electronic mail with a panel of experts on respiratory disease from primary and secondary care in Portugal. In the first round, the research needs in respiratory disease in Portugal were identified. In the second round, 196 research questions in six disease areas, derived from the first round and from the IPCRG Respiratory needs statement, were prioritised on a five-point Likert-type scale. In the third round, the questions were prioritized again with feed-back provided on the median scores for each item in the second round. Consensus was considered to have been reached when 80 % of the participants gave a score of 4 or 5 out of five on a given item., Results: The 40 experts identified 121 respiratory research questions in Round 1 and expressed their views on 196 questions in Rounds 2 and 3. Twelve research questions (6 %) reached consensus. There were five questions in the asthma domain on early diagnosis, pulmonary function tests, the use of inhalers, and adherence to treatment. There were four questions in the chronic obstructive pulmonary disease domain on vaccinations, on routine monitoring and evaluation of treatment, on diagnosis, and on adherence to treatments. There was one question in the smoking domain on the effects of brief counselling. There were two questions on respiratory tract infections on the treatment of children and on the prescription of antibiotics. An additional 23 research questions (12 %) achieved consensus between 75 and 79 %., Conclusion: The results reflect the Portuguese reality in response the international agenda for research on respiratory diseases published by the IPCRG. They can support the development of future respiratory disease research in Portugal.

Background: Performance indicators assessing the quality of medical care and linked to pay for performance may cause disagreement. Portuguese indicators included in recent health care reform are controversial., Objectives: To obtain consensus from opinion leaders in family medicine regarding the performance indicators for practice management used in the evaluation of Family Health Units in Portugal., Methods: Eighty-nine specialists in primary care were invited to answer the following question in an online Delphi study: 'Which performance indicators should be assessed regarding the organization and management of clinical practice in primary care in Portugal?' A Likert scale was used to evaluate validity, reliability, feasibility and sensitivity to change. Twenty-seven experts participated in the second round and achieved a high degree of consensus. Eight categories were created for analysis., Results: The experts suggested the use of existing indicators as well as new indicators. Thirty-nine indicators suggested by the experts are currently in use in Portugal. The assessment of the number of clinical acts performed, the number of administrative acts, and evaluation of the clinical demographic profile achieved a high degree of consensus. The expert panel suggested fifty new indicators. Five categories of these new indicators had a high degree of consensus, and three categories had a low degree of consensus., Conclusion: The expert panel recommended that performance indicators of practice management should first assess the quantity of clinical and administrative activities undertaken. These indicators must take into account the human and financial resources available to the clinic and its demographic context.

The scope of this review was to assess the strength of evidence of Portuguese performance indicators on Cervical Cancer screening: (1) age group of the women that should be screened for cervical cancer; (2) frequency of screening; and (3) the best method for screening. The following MeSH terms were searched: vaginal smears, age groups, periodicity, methods, uterine cervical cancer. Articles not reflecting the study objectives or not available in English, Portuguese or Spanish were excluded. The SORT classification was used to rate the articles selected.Of the 197 articles found, 9 that met all study criteria were selected for inclusion in this review. These included 1 systematic review, 1 randomized controlled clinical trial, 2 retrospective studies and 5 clinical guidelines. The authors also chose to include 4 clinical guidelines and two systematic reviews relevant to the Portuguese population even though they did not appear in the initial search of the literature. The studies suggest screening women between the ages of 21 to 25 years and 65 years of age, once every three years using conventional cytology. There is still controversy regarding the three objectives of this study (target age bracket, screening frequency and screening method).

The scope of this review was to assess the strength of evidence for the current Portuguese performance indicator on breast cancer screening with mammography in order to determine the recommended age group and periodicity for screening. A search for articles was conducted in the main international databases of medical literature. Articles published between January 2006 and January 2012 addressing the objectives of this review were included. The SORT taxonomy was used to classify the results. Of the 253 articles, five articles met the inclusion criteria and were selected for review. These included three systematic reviews, one meta-analysis and one clinical guideline based on a systematic review. A reduction in breast cancer mortality with mamography screening was the outcome in all articles selected. Mammography screening between 50 and 69 years was recommended in all articles that assess this age group. The clinical guidelines recommended screening every two years. In conclusion, the current literature recommends mammography for women every two years between the ages of 50 and 69 years. This is consistent with the current performance indicator for breast cancer screening in Portugal.

Background: Acute sinusitis is a common reason for primary care visits. It causes significant symptoms and often results in time off work and school., Objectives: We examined whether intranasal corticosteroids (INCS) are effective in relieving symptoms of acute sinusitis in adults and children., Search Methods: We searched CENTRAL 2013, Issue 4, MEDLINE (January 1966 to May week 2, 2013), EMBASE (1990 to May 2013) and bibliographies of included studies., Selection Criteria: Randomised controlled trials (RCTs) comparing INCS treatment to placebo or no intervention in adults and children with acute sinusitis. Acute sinusitis was defined by clinical diagnosis and confirmed by radiological evidence or by nasal endoscopy. The primary outcome was the proportion of participants with either resolution or improvement of symptoms. Secondary outcomes were any adverse events that required discontinuation of treatment, drop-outs before the end of the study, rates of relapse, complications and return to school or work., Data Collection and Analysis: Two review authors independently extracted data, assessed trial quality and resolved discrepancies by consensus., Main Results: No new trials were found for inclusion in this update. Four studies involving 1943 participants with acute sinusitis met our inclusion criteria. The trials were well-designed and double-blind and studied INCS versus placebo or no intervention for 15 or 21 days. The rates of loss to follow-up were 7%, 11%, 41% and 10%. When we combined the results from the three trials included in the meta-analysis, participants receiving INCS were more likely to experience resolution or improvement in symptoms than those receiving placebo (73% versus 66.4%; risk ratio (RR) 1.11; 95% confidence interval (CI) 1.04 to 1.18). Higher doses of INCS had a stronger effect on improvement of symptoms or complete relief: for mometasone furoate 400 µg versus 200 µg (RR 1.10; 95% CI 1.02 to 1.18 versus RR 1.04; 95% CI 0.98 to 1.11). No significant adverse events were reported and there was no significant difference in the drop-out and recurrence rates for the two treatment groups and for groups receiving higher doses of INCS., Authors' Conclusions: Current evidence is limited for acute sinusitis confirmed by radiology or nasal endoscopy but supports the use of INCS as a monotherapy or as an adjuvant therapy to antibiotics. Clinicians should weigh the modest but clinically important benefits against possible minor adverse events when prescribing therapy.

The clinical efficacy of antibiotics depends on their correct use. Widespread ignorance and inappropriate attitudes to antibiotic use have been identified among consumers. In order to improve the knowledge of middle-school students on antibiotics and their correct use, 82 ninth-grade students were enrolled in a teaching activity. The teaching activity consisted of a slide show presentation followed by discussion in a regular class. To evaluate the impact of the teaching activity the students were asked to answer a questionnaire before and after the activity. This study aimed: (1) to evaluate knowledge on the use of antibiotics in students of two schools in the north of Portugal and (2) to evaluate the efficacy of the school intervention in improving students' knowledge on correct antibiotic use. We found lack of knowledge among students regarding antibiotic spectra and indications and incorrect attitudes in the pre-test. Significant increases in knowledge were observed after implementation of the teaching activity. Knowledge of the correct use of antibiotics for bacterial diseases rather than viral diseases rose from 43% to 76% in the post-test (p < 0.01). Knowledge of the risk of bacterial resistance to antibiotics from their incorrect use rose from 48% to 74% in the post-test (p < 0.05). We believe that it is important to reinforce the teaching activities on microbiology and antibiotic use at the middle school level.

Background: Self-assessment of asthma and a stronger doctor-patient relationship can improve asthma outcomes. Evidence for the influence of patient enablement on quality of life and the control of asthma is lacking., Aims: To assess asthma severity, medication use, asthma control, and patient enablement in patients with asthma treated in primary care and to study the relationship between these variables and quality of life., Methods: A cross-sectional study was conducted in an urban clinic in northern Portugal. Data were collected from both clinical records and questionnaires from a random sample of asthma patients. The modified Patient Enablement Instrument, the Asthma Quality of Life Questionnaire, and the Asthma Control Questionnaire were used. Peak expiratory flow and forced expiratory volume in one second (FEV1) were measured. Receiver operating characteristic curve analysis was performed to establish cut-off values for the quality of life measurements. The associations between enablement, asthma control, and quality of life were tested using logistic regression models., Results: The study sample included 180 patients. There was a strong correlation between asthma control and quality of life (r=0.81, p<0.001). A weak association between patient enablement and asthma control and quality of life was found in the logistic regression models. Poor control of asthma was associated with female gender, concomitant co-morbidities, reduced FEV1, and increased severity of asthma., Conclusions: The weak correlation between enablement and asthma control requires further study to determine if improved enablement can improve asthma outcomes independent of gender, severity, and concomitant co-morbidities. This study confirms the strong correlation between asthma control and quality of life.

Background: Internet use by patients as a source of information on health and disease is expanding rapidly with obvious effects on the doctor-patient relationship. Many of these effects remain undocumented or are poorly understood., Objectives: To assess the use of the internet for health information by patients in primary care in Israel and their perception of the effects of internet use on their relationship with their doctor., Methods: A cross-sectional survey was conducted among a convenience sample of patients visiting 10 primary care clinics in central Israel using a questionnaire developed for this survey. The survey examined attitudes to using the internet for health-related information and attitudes to sharing this information with doctors. Associations between demographic variables, internet use and patient satisfaction with the doctor's response were tested using the chi-square statistic and t-tests., Results: Completed questionnaires were received from 138 patients; the response rate was 69%. Patients in the study sample had a high rate of internet access (87%), with many using the internet as a source of health information (41%) although most patients using the internet never share this information with their doctor (81%). Among those who share information with the doctor, most felt that this has a positive effect on the relationship (870/%). Few patients reported being referred to websites by the doctor (28%)., Conclusions: Internet use is prevalent in this population, though physicians may be unaware of this. Future study could examine the effects of doctors who ask patients actively about their internet use and inform them of relevant health information sources online.

Aims: Asthma is frequently under-diagnosed with a wide variation in incidence rates. We aimed to assess how physicians in a Portuguese sentinel practice network perform using standardised diagnostic criteria., Method: Patients consulting one of the 43 network physicians with complaints suggestive of asthma were enrolled in the study over a four-year period. Symptom frequency and diagnoses of asthma were tabulated. Diagnostic accuracy was computed by dividing the rate of asthma diagnosis by the true rate using established diagnostic criteria., Results: Over four years, 43 physicians followed 32,103 patients (128,412 patient-years) and diagnosed asthma in 310. The diagnosis was confirmed in 260 cases, giving a true incidence rate of 2.02/1000/year (95% confidence interval 1.8 to 2.2) and an accuracy of diagnosis of 84%., Conclusions: Asthma incidence approaches published rates if accepted criteria are used. Educational efforts to ensure more accurate diagnosis may improve outcomes for asthma patients.

Background: Acute uncomplicated lower urinary tract infection (UTI) is one of the most common problems for which young women seek medical attention., Objectives: To compare the efficacy, resistance development and safety of different antimicrobial treatments for acute uncomplicated lower UTI., Search Strategy: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Renal Group's Specialised Register, MEDLINE, EMBASE and bibliographies of included studies., Selection Criteria: Randomised controlled trials (RCTs) comparing different classes of antimicrobials for acute uncomplicated UTI in women were included. The outcomes of interest were symptomatic and bacteriological cure at short and long-term follow-up, resistance development, number of days to symptom resolution, days of work loss, adverse events and complications., Data Collection and Analysis: Two authors independently extracted the data and assessed study quality. Statistical analyses were performed using the random effects model and the results expressed as risk ratios (RR) with 95% confidence intervals (CI)., Main Results: Trimethoprim-sulfamethoxazole (TMP-SMX) was as effective as fluoroquinolones in achieving short-term (RR 1.00, 95% CI 0.97 to 1.03) and long-term (RR 0.99, 95% CI 0.94 to 1.05) symptomatic cure. Beta-lactam drugs were as effective as TMP-SMX for short-term (RR 0.95' 95% CI 0.81 to 1.12) and long-term (RR 1.06' 95% CI 0.93 to 1.21) symptomatic cure. Short-term cure for nitrofurantoin was similar to that of TMP-SMX (RR 0.99' 95% CI 0.95 to 1.04) as was long-term symptomatic cure (RR 1.01' 95% CI 0.94 to 1.09).Fluoroquinolones were more effective than beta-lactams (RR 1.22, 95% CI 1.13 to 1.31) for short-term bacteriological cure. Rashes were more frequent in patients treated with TMP-SMX than with nitrofurantoin or fluoroquinolones and in patients treated with beta-lactam drugs compared to fluoroquinolones. Minimal data were available on the emergence of resistant strains during or after antimicrobial treatment., Authors' Conclusions: No differences were observed between the classes of antimicrobials included in this review for the symptomatic cure of acute uncomplicated UTI. Fluoroquinolones proved more effective than beta-lactams for the short-term bacteriological outcome, probably with little clinical significance. Individualised treatment should take into consideration the predictable susceptibility of urinary pathogens in local areas, possible adverse events and resistance development, and patient preference.

Background: Specific laboratory tests are required to ensure adequate management of patients with hypertension, according to internationally accepted guidelines. There is wide variation in doctor test ordering behaviour. Many factors are known to affect this. Little is known about the interaction between doctor, patient and practice characteristics. The current study was designed to explore this., Methods: A series of eight case vignettes was designed to examine test ordering behaviour among primary care doctors in Poland. The cases differed with regard to the level of blood pressure and the presence or absence of other cardiovascular risk factors, including diabetes. Doctors stated their choices of laboratory investigations needed in these cases. Their responses were compared with recommendations in the 2003 European Society of Hypertension/European Society of Cardiology hypertension guidelines. Associations between the correct responses and patient, doctor and practice characteristics were tested., Results: One hundred and twenty-five out of 192 invited doctors (65%) participated in the study. They ordered a mean of 4.9 laboratory tests per case. This represents 47.9% of the tests recommended by current guidelines. Older doctors working in smaller practices and private settings ordered fewer laboratory tests. Specialization in family medicine was associated with greater compliance with guidelines. Grade 2 hypertension and the presence of other risk factors of cardiovascular disease were associated with ordering more tests but the presence of diabetes did not improve compliance with guidelines., Conclusions: Further educational efforts are needed to promote rational test ordering for hypertensive patients by Polish primary health care doctors.

Background: Medical consultations are replete with conflicts, particularly in the current era of explicit and implicit rationing practices in health care organizations. Although such conflicts may challenge the doctor-patient relationship, little is known about them or their consequences., Aims: To systematically describe the nature of doctor-patient conflicts in medical encounters and the strategies physicians use when faced with conflicts., Methods: Analysis of 291 videotaped routine encounters with 28 general practitioners, using a novel adaptation of the Roter interaction analysis system software, provided quantitative empirical data on the conflicts and on the communication process. Seven focus groups (56 GPs) provided qualitative insights and guided the analysis., Results: Conflicts were identified in 40% of consultations; 21% of these were related to the rationing of health care resources. In conflictual encounters, both the opening and closing phases of the encounter were shorter than in non-conflictual encounters. In coping with resource rationing, the commonest strategy was to accept the dictates of the system without telling the patients about other options. When conflict of this type occurred, doctors showed more opposition to the patients rather than empathy., Conclusions: Doctors often face conflicts in their routine work, but resource-related conflicts are especially difficult and expose the dual loyalties of the doctor to the patient and to the system. Insights derived from this research can be used to design training interventions that improve doctors' efficacy in coping with conflicts and ultimately allow them to provide better patient care.

Rationale, Aims and Objectives: Compliance with treatment guidelines for hypertension is variable. This study assessed the competence of Polish general practitioners in compliance with hypertension treatment guidelines, and doctor and patient characteristics associated with compliance., Methods: The study was conducted on a random sample of Polish primary-care doctors working in clinics contracted by the national health insurance funds. Doctors completed a questionnaire consisting of eight case vignettes describing patients with elevated blood pressure. The cases differed on three variables relating to the level of blood pressure, the presence or absence of diabetes mellitus, and the presence or absence of other risk factors. Doctors were asked to give their treatment decision for each case. Demographic data and details of the doctor's practice were also collected. Treatment decisions were tabulated, and associations between doctor and patient characteristics and treatments were assessed., Results: One hundred twenty-five doctors (65% response rate) completed the questionnaire. Compliance with treatment guidelines was judged to be 51%. Poor compliance with guidelines was noted for patients with diabetes mellitus. The level of blood pressure was the strongest predictor of drug treatment. Angiotensin-converting enzyme inhibitors were the most frequently prescribed medications. Appropriate decisions were associated with practice in large cities., Conclusions: Compliance with hypertension treatment guidelines was judged to be poor in this study of a sample of Polish primary-care doctors using case vignettes to test competence. Additional emphasis on hypertension guidelines in training doctors is needed, especially for diabetic patients and for doctors outside urban centres.

Background: Acute sinusitis is a common reason for primary care visits. It causes significant symptoms and often results in time off work and school., Objectives: We examined whether intranasal corticosteroids (INCS) are effective in relieving symptoms of acute sinusitis., Search Strategy: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2008, issue 4) which contains the Acute Respiratory Infections Group's Specialized Register, MEDLINE (January 1966 to October 2008), EMBASE (1990 to October 2008) and bibliographies of included studies., Selection Criteria: Randomized controlled trials (RCTs) were considered eligible if they compared INCS treatment to placebo treatment of a control group for acute sinusitis; acute sinusitis was defined by clinical diagnosis and confirmed by radiological evidence or by nasal endoscopy. The primary outcome was the proportion of participants with either resolution or improvement of symptoms. Secondary outcomes were any adverse events that required discontinuation of treatment, drop-outs before the end of the study, rates of relapse, complications and return to school or work., Data Collection and Analysis: Two review authors independently extracted the data, assessed trial quality and resolved discrepancies by consensus., Main Results: Four studies with 1943 participants met the inclusion criteria. The trials were well designed, double-blind, placebo controlled in which the included participants had acute sinusitis. The treatment assigned was INCS versus control treatment for 15 or 21 days. The rates of loss to follow up in the studies were 7%, 11%, 41% and 10%. When the results from the three trials included in the meta-analysis were combined, participants receiving INCS were more likely to have resolution or improvement of symptoms than those receiving placebo (73% versus 66.4%; risk ratio (RR) 1.11; 95% CI 1.04 to 1.18). Higher doses of INCS had a stronger effect on improvement or complete relief of symptoms: for mometasone furoate (MFNS) 400 mcg versus 200 mcg, (RR 1.10; 95% CI 1.02 to 1.18 versus RR 1.04; 95% CI 0.98 to 1.11). No significant adverse events were reported and there was no significant difference in the drop-out and recurrence rate for the two treatment groups and for groups receiving higher doses of INCS., Authors' Conclusions: For acute sinusitis confirmed by radiology or nasal endoscopy, current evidence is limited, but supports the use of INCS as a monotherapy or as an adjuvant therapy to antibiotics. Clinicians should weigh the modest but clinically important benefits against possible minor adverse events when prescribing therapy.

Background: The Internet has transformed the patient-physician relationship by empowering patients with information. Because physicians are no longer the primary gatekeepers of medical information, shared decision making is now emerging as the hallmark of the patient-physician relationship., Objectives: To assess the reactions of primary care physicians to encounters in which patients present information obtained from the Internet (e-patients) and to examine the influence of the physicians' personal and demographic characteristics on their degree of satisfaction with e-patients., Methods: A questionnaire was developed to assess physicians' attitudes to e-patients, their knowledge and utilization of the Internet, and their personal and professional characteristics. Family physicians in central Israel were interviewed by telephone and in person at a continuing medical education course., Results: Of the 100 physicians contacted by phone, 93 responded to the telephone interviews and 50 physicians responded to the questionnaire in person. There was an 85% response rate. The mean age of respondents was 49 years. Most physicians were born in Israel, with a mean seniority of 22 years. Most had graduated in Eastern Europe, were not board certified and were employees of one of the four health management organizations in Israel. Most physicians responded positively when data from the Internet were presented to them by patients (81%). A number of respondents expressed discomfort in such situations (23%). No association was found between physicians' satisfaction in relationships with patients and comfort with data from the Internet presented by patients., Conclusions: Physicians in this sample responded favorably to patients bringing information obtained online to the consultation. Though it may be difficult to generalize findings from a convenience sample, Israeli family physicians appear to have accepted internet use by patients.

The objective of this study was to assess the effect of a biopsychosocial intervention on patients' feelings of well-being, perceptions of health and health indicators before and after treatment in a clinic for primary care frequent attenders. One hundred patients referred to a community-based clinic were assessed using the WONCA-COOP charts and MOS-SF36 questionnaires before and after treatment with an intervention consisting of a narrative interview, short-term cognitive-behavioral therapy, stress reduction techniques and medication. Sixty-three out of 100 patients who completed the COOP charts at intake completed them again at follow-up and 35 patients out of 40 who completed the MOS-SF36 at intake completed them at follow-up. Statistically significant improvement was noted in five out of six categories on the COOP charts ("physical fitness" "emotions", "social function", "daily activity" and "general health status") and in four out of eight categories of the MOS ("emotional health", "physical health", "social functioning", and "pain"). We concluded that in this uncontrolled study, a biopsychosocial intervention produced a positive effect on function and self-perception of health in a group of frequent attenders from primary care.

Background: Instruction in principles and methods of medical education is a core component of the training of medical teachers. Curricula for new medical teachers have developed across Europe, but few European courses have had the success of the EURACT Bled course for teachers of family medicine. The course focuses on practical issues in medicine and the professional development of physicians. This article describes 16 years' experience with the Bled course for teachers in general practice/family medicine (GP/FM)., Course Structure: The course is centred on the preparation of a teaching module, exploring a specific theme in family medicine. The main teaching methods used are: keynote lectures, small group sessions, field work and preparation of a teaching module by the participants., Outcomes: This course has attracted 555 participants from 20 countries since 1992. The course and its outputs have been applied in undergraduate and postgraduate teaching, and in continuous professional development (CPD) in several countries. It is a respected forum for faculty development. The experience of the Bled course suggests that academic medicine may be better able to fulfil its responsibilities by paying attention to relevant topics and using appropriate methods in undergraduate and postgraduate medical curricula.

Background: Many faculties of medicine now include programmes using early clinical exposure (ECE) to introduce medical students to important topics in medicine., Objective: To sketch the landscape of ECE in Europe, describing existing courses., Methods: A survey questionnaire was developed by the Basic Medical Education Committee of the European Academy of Teachers in General Practice (EURACT). This survey used the key informant interviews method, with EURACT Council members serving as key informants by filling in the questionnaire and gathering descriptive data on ECE programmes in their own countries., Results: We asked representatives of 32 EURACT member countries to complete the questionnaire in 2006. We received responses from 21 countries, and the programmes of 40 medical schools from 16 countries were included in the study. Thirty-two medical schools implemented ECE starting in the first year. The duration of ECE programmes ranged from 2 weeks to 2 years. The length of each session varied from 2 hours to a full day. Primary care played an important role in ECE. ECE programmes were implemented with a wide range of objectives., Conclusion: ECE is a new and rewarding trend in European medical schools, and general practice/family medicine (GP/FM) departments are widely involved in these teaching activities. This could help establish GP/FM departments in some countries that still do not have them in their medical schools.

Background: Several dietary factors have been considered to be involved in the increasing incidence of colorectal cancer in industrialised countries. Experimental and epidemiological evidence has been suggestive but not conclusive for a protective role for high dietary calcium intake. Intervention studies with colorectal cancer as an endpoint are difficult to perform owing to the large number of patients and the long follow-up required; studies using the appearance of colorectal adenomatous polyps as a surrogate endpoint are therefore considered in reviewing the existing evidence., Objectives: This systematic review aims to assess the effect of supplementary dietary calcium on the incidence of colorectal cancer and the incidence or recurrence of adenomatous polyps., Search Strategy: We searched the Cochrane Controlled Trials Register, the Cochrane Colorectal Cancer Group specialised register, MEDLINE, Cancerlit , and Embase, to July 2007. The reference lists of identified studies were inspected for further studies, and the review literature was scrutinized., Selection Criteria: Randomised controlled trials of the effects of dietary calcium on the development of colonic cancer and adenomatous polyps in humans are reviewed. Studies of healthy adults and studies of adults at higher risk of colon cancer due to family history, previous adenomatous polyps, or inflammatory bowel disease were considered; data from subjects with familial polyposis coli are excluded. The primary outcomes were the occurrence of colon cancer, and occurrence or recurrence of any new adenomas of the colon. Secondary outcomes were any adverse event that required discontinuation of calcium supplementation, and drop-outs before the end of the study., Data Collection and Analysis: Two reviewers independently extracted data, assessed trial quality and resolved discrepancies by consensus. The outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI). The data were combined with the fixed effects model., Main Results: Two studies with 1346 subjects met the inclusion criteria. Both trials were well designed, double - blind, placebo controlled trials, included participants with previous adenomas. The doses of supplementary elemental calcium used were 1200 mg daily for a mean duration of 4 years, and 2000 mg/day for three years. The rates of loss to follow -up were 14 % and 11%. For the development of recurrent colorectal adenoma, a reduction was found (OR 0.74, CI 0.58,0.95) when the results from both trials were combined., Authors' Conclusions: Although the evidence from two RCTs suggests that calcium supplementation might contribute to a moderate degree to the prevention of colorectal adenomatous polyps, this does not constitute sufficient evidence to recommend the general use of calcium supplements to prevent colorectal cancer.

Background: Smoking continues to be the most significant preventable cause of morbidity and early mortality in the developed world. Primary care physicians are not fufilling their potentially vital and effective role with regard to tobacco use and dependence., Objectives: To evaluate current primary care physician practise in promoting smoking cessation., Methods: This observational study evaluated physician recording of smoking status by analysis of patients' electronic medical records. The 126 primary care physicians were based in 23 Tel Aviv clinics treating 144,811 patients. We also assessed additional physician anti-smoking activities by a telephone questionnaire of 178 randomly selected patients., Results: Analysis of the EMRs revealed that an average of 4.4% of patients per physician were recorded as smokers (as compared to a known smoking rate in this patient population of 24%). Male physicians recorded a significantly higher proportion of their patients as smokers in the EMR compared to female physicians (P < 0.05). A non-significantly higher rate of recording smokers was found in doctors who had completed postgraduate specialization in family medicine as compared to non-specialists. The questionnaire results show that 41% of patients interviewed recalled being asked if they smoked and 31% of smoking patients had been advised to quit. A non-significantly higher proportion of male as compared to female patients reported being questioned if they smoked, and if they were smokers, being advised to quit., Conclusions: This study shows low rates of physician intervention to promote smoking cessation. It appears that a large proportion of the primary care physicians surveyed do not follow recommendations to promote smoking cessation among their patients. Intervention among adolesent smokers was particularly inadequate. Further action is needed to improve the performance of physicians in aiding smoking cessation.