Hospital Family Medicine Research Articles

Exploring attitudes towards infertility: insights from a primary healthcare setting

Aim: This study aimed to assess attitudes and knowledge regarding infertility among adults attending a primary healthcare facility in Turkey, along with identifying influencing factors. Methods: A descriptive cross-sectional survey was conducted among individuals aged 18-49 who admitted to a Hamidiye tranining and research hospital Family Medicine Outpatient Clinic. Participants completed the attitudes towards infertility scale (ATIS) and the Infertility Knowledge Test (IKT). Demographic data including age, gender, marital status, educational level, and reproductive history were collected. Results: A total of 237 individuals participated in the study. The median ATIS score of the participants in the study was 50, and the median IKT score was 19. ATIS scores were lower among male (p:0,023), those who were married, had children, had experienced pregnancy, had lower education level compared to other groups (p

Structural Brain Alterations in Metabolic Syndrome: A Comprehensive MRI Volumetric Analysis of Subcortical and Associated Structures.

Objective: This study aims to elucidate the comprehensive effects of metabolic syndrome (MetS) on the structural integrity of subcortical brain regions and associated structures through high-resolution magnetic resonance imaging (MRI) volumetric analysis, thereby contributing to a deeper understanding of the neuroanatomical dimensions of MetS and its potential implications for cognitive functions and overall brain health. Methods: A cross-sectional design was implemented, involving 25 individuals diagnosed with MetS for at least one year and a healthy control group of 15 individuals at a tertiary hospital's family medicine clinic in Eastern Turkey. Participants underwent a high-resolution MRI scan using a 1.5T Siemens Aera scanner. The MRICloud platform was employed for comprehensive segmentation and quantitative analysis of various brain structures. Results: The study revealed significant volumetric reductions in all measured subcortical brain regions among individuals with MetS compared to the control group (all P < 0.05). Notable differences were observed in key structures such as the substantia nigra, corpus callosum, and thalamus. In subcortical structures, the largest volumetric differences were noted in the basal ganglia L (1322.4 mm³), while the most significant percentage differences were seen in the substantia nigra R (25.24%) and caudate nucleus L (21.02%). Conclusion: The findings from this study underscore the significant neuroanatomical changes associated with MetS, manifesting as volumetric reductions in critical subcortical brain areas. These alterations underscore the necessity for further research into the comprehensive influence of MetS on cognitive processes and the potential for early therapeutic interventions.

Impact of a peer-support programme to improve loneliness and social isolation due to COVID-19: does adding a secure, user friendly video-conference solution work better than telephone support alone? Protocol for a three-arm randomised clinical trial

IntroductionThe COVID-19 pandemic has forced the implementation of physical distancing and self-isolation strategies worldwide. However, these measures have significant potential to increase social isolation and loneliness. Among older people, loneliness...

How well is acupuncture known?

In our study, we aimed to assess participants' attitudes and knowledge of the use of acupuncture among those who were 18-65 years old. During the period of May 1–June 1, 2023, a descriptive cross-sectional study was carried out. Between the stated dates, anyone between the ages of 18 and 65 who applied to the Health Sciences University Şişli Hamidiye Etfal Training and Research Hospital's Family Medicine Outpatient Clinics for any reason and who accepted to participate in the study were included. The researcher administered the 24 questioned data form face-to-face with the individuals after obtaining their sociodemographic characteristics, chronic illnesses, knowledge of various TCM treatments and acupuncture. Among the participants, 167 people (73.6%) had information about acupuncture. Acupuncture was one of the most used applications in our survey, and most of the patients who experienced it were referred by physicians. Those who previously received acupuncture treatment knew more about the practice with a statistically significant difference (p=0.004). Those who knew about acupuncture and those who had previously had acupuncture said there was no danger or damage in receiving acupuncture, with a statistically significant difference (p=0.015, p=0.0001, respectively). Although acupuncture is one of the most well-known TCM uses, its use remains in the background. The internet being the most widely used information source limits access to reliable data. Acupuncture should be performed, like all TCM applications, by qualified physicians in authorized centers while taking the outcomes into consideration.

Obesity Prevalence, Associated Factors and Complications among Adult Population Attending Family Medicine Clinic in Hatta Hospital, United Arab Emirates

Background: The United Arab Emirates (UAE) has experienced rapid economic growth in the last few decades, resulting in swift urbanization and an influx of foreign labor. This has facilitated an advanced, yet sedentary lifestyle characterized by increased reliance on technology, unhealthy dietary habits, and a reduction in physical activity levels. These factors significantly contributed to the rise in the prevalence of obesity. Objective: To determine the prevalence of obesity, it is associated factors, and complications among adults presenting to the primary care clinic at Hatta Hospital, located in the Hatta area UAE. Material &amp; Methods: This cross-sectional study enrolled adult Emirati patients aged between 18-55 years. Body Mass Index (BMI) was categorized based on the World Health Organization’s threshold. Patients’ socio-demographic and clinical data was obtained and recorded. Results: A total of 600 Emirati patients were included in this study, with a median age of 33 (IQR=25-45) years. Gender distribution was kept equal with 50.5% male and 49.5% female participants. The median BMI among the participants was 28.2 (IQR=24.3-32.5) kg/m2. The prevalence of underweight, normal weight, overweight, and obesity was found as 4.3%, 23.5%, 33.7% and 38.5% respectively. After adjusting the co-variants in the multivariable model, lower education levels were found to be significantly associated with higher odds of obesity. Conversely, being single and adhering to a healthy lifestyle was associated with lower odds of obesity in the multivariable model. Conclusion: The present study identified that 38.5% of the adult population attending Hatta Hospital family medicine clinics were obese and 33.7% were overweight. Conclusively 72.2% of the adult population of the Hatta area have a BMI above normal, indicating a very high prevalence of obesity and overweight cases. Furthermore, a significant association of obesity was found with lower education levels, being married, having unhealthy dietary habits, and insufficient physical activity.

Evaluation of Patients aged over 65 years who applied to Ankara Training and Research Hospital Family Medicine Outpatient Clinics: Comparison Before and After Covid-19 Pandemic

Aim: Taking into account the importance and priority of the geriatric age group, the aim of our study was to examine the reasons for and the number of visits to primary health care institutions, to compare them before and after the Covid-19 pandemic, and to draw attention to the importance of geriatric sciences in family medicine specialty training in the light of this evaluation.&#x0D; &#x0D; Materials and Methods: Patients who applied to the Ankara Training and Research Hospital (EAH) Family Medicine Outpatient Clinics between 01.03.2020-31.12.2022 constitute the population of the study. Patients were retrospectively evaluated before and after the Covid-19 pandemic according to their admission rates and diagnoses. The outpatient clinics they applied to were analyzed. Musculoskeletal system problems were analyzed under a separate heading according to diagnoses.&#x0D; Results: Out of 47014 diagnoses above the age of 65 during the pandemic period, I10 - Essential (Primary) Hypertension was the most common diagnosis, except for general medical examinations and screening examinations. In the post-Covid-19 period, 45928 diagnoses were made in 14398 patients over the age of 65. After general medical and laboratory examinations, the most common diagnose was I10 Essential Hypertension in both period. Musculoskeletal complaint during the pandemic period was the second most common with the diagnosis of M79.1 Myalgia in both period. Musculoskeletal complaints especially myalgia was more common in the pandemic period than the post-covid period (p

Evaluation of patient satisfaction in Ankara traıning and research hospital family medicine polyclinics

Amaç: Hasta memnuniyet düzeylerinin belirlenmesi ve etkileyen faktörlerin ortaya konması ile daha nitelikli sağlık hizmet sunulması sağlanabilir. Bu çalışmada, aile hekimliği polikliniklerimizdeki hasta memnuniyetini saptamak amaçlanmıştır.&#x0D; Gereç ve Yöntemler: 18 yaş üstü 270 gönüllü erişkin hasta çalışmaya dâhil edildi. Hastaların sosyodemografik özelliklerini, alışkanlık durumlarını sorgulayan bir anket ve Ayaktan Hasta Memnuniyet Ölçeği katılımcılara yüz yüze görüşme esnasında uygulandı.&#x0D; Bulgular: Katılımcıların 78 (%28.88)’u erkek, 192 (%71.11)’i kadın ve yaş ortalaması 41.72±15 yıl idi. Katılımcıların %94.07’inin aile hekimliği polikliniğine tekrar gelmek istediği, %95.92’sinin tavsiye ettiği gözlenmiştir. Tüm katılımcıların ölçek ortalama puanı 111.25±27.67 olarak bulundu. Katılımcıların ölçek toplam ve alt boyut puanları ile yaş, cinsiyet, medeni durum arasında istatistiksel olarak anlamlı bir farklılık saptanmadı (p&gt;0.05). Katılımcıların eğitim durumu lise altı olanların “Genel memnuniyet” puanları daha yüksek bulundu (p=0.044). Katılımcıların mesleki durumu çalışmıyor olanların ölçek toplam puanları daha yüksek bulundu (p=0.035). &#x0D; Sonuç: Hasta memnuniyetinin eğitim düzeyi, meslek grubu gibi sosyodemografik verilere göre değiştiği görülmüştür. Hasta memnuniyetini olumlu etkileyen faktörlerin doğru bir hasta-hekim ilişkisi ve iyi iletişim becerileri olduğunu düşünmekteyiz.

Family Medicine Residents Awareness of Rational Drug Use in Geriatric Patients and Their Need for a Web Application

The term polypharmacy is generally known as the simultaneous use of five or more medicines. An increase in polypharmacy is also observed with chronic diseases, which increases with age. The main complications of polypharmacy are medicine side effects, inappropriate medicine use, drug-drug interaction, and drug-disease interactions. Family physicians are the most effective physician group in coordinating medicine therapy, as they provide continuous, longitudinal, and comprehensive medical care to the individual. In this study, it was aimed to determine the need of an auxiliary web application regarding family medicine residents' awareness of polypharmacy side effects in geriatric population and to identify the barriers to rational drug use in their daily clinical practice. The research is a cross-sectional observational study, and all residents actively working in the Ankara City Hospital Family Medicine Clinic were planned to be included and were invited to the study. The study was conducted through survey application method under observation. It was determined that geriatric patients mostly referred to their "clinical experience" in rational drug use according to the participants. The obstacles faced by the participants in rational drug use were mostly in that of "not having enough knowledge" and "patient-centered medicine regulation to be difficult and time consuming". 75.3% of respondents (n=70) marked strongly agree and 18.3% marked agree (n=17) for the statement "I would like to have an easily accessible an artificial intelligence aided web application that I can use in my daily practice regarding polypharmacy side effects, such as drug-drug interactions, drug-chronic disease incompatibility, potentially inappropriate medicine (PIM) in the elderly" and the mean value of this proposition was determined as 4.65±0.7. This study showed that the resources used to detect polypharmacy and its complications were not used adequately and appropriately. Moreover, the study results present the need and demand for time-saving and facilitating auxiliary web applications to minimize PIM, drug-drug interaction, drug-chronic disease interaction in the elderly and to evaluate it in the light of current data to provide person-centered and comprehensive care in the clinician's practice.

Creating healing spaces for residents using Narrative Medicine

Factors that detract from making meaningful connections with patients and finding meaning and joy in medical practice have found their way into resident education. Burnout and moral injury are increasingly reported by residents across specialties. [1, 2] A curriculum in Narrative Medicine was established at a community hospital family medicine residency as an antidote to these influences. Evaluative survey data and qualitative semi structured interviews reveal that the program created healing spaces for residents. This essay describes the program features and the evidence provided by the residents endorsing the healing impact of the program.

Socio-demographic and Clinical Characteristics of Patients Admitted to a Pandemic Hospital Family Medicine Outpatient Clinic during the Covid-19 Pandemic

Socio-demographic and Clinical Characteristics of Patients Admitted to a Pandemic Hospital Family Medicine Outpatient Clinic during the Covid-19 Pandemic

Covid-19 anksiyete sıklığında sosyal medya bağımlılığının rolü nedir? Kesitsel bir çalışma.

Amaç: Pandemi sürecinde gerek iletişim gerek bilgilenme amacı ile sosyal medya maruziyeti artmıştır. Bu çalışmanın amacı koronavirüs anksiyetesi ile sosyal medya bağımlılığı arasındaki ilişkiyi saptamaktır.&#x0D; Gereç ve Yöntem: Tek merkezli, kesitsel tipte olan araştırmaya Gaziosmanpaşa Eğitim ve Araştırma Hastanesi Aile Hekimliği Polikliniği’ne 15 Eylül 2020- 15 Ekim 2020 tarihleri arasında başvuran 297 hasta alındı. Katılımcılara Koronavirüs Anksiyete Ölçeği (KAÖ) kısa formu, Hasta Sağlık Anketi-9 (PHQ-9), Bergen Sosyal Medya Bağımlılığı Ölçeği (BSMBÖ) uygulandı. Elde edilen verilerin istatistiksel analizleri için IBM SPSS Statistics 22 (IBM SPSS, Türkiye) programı kullanıldı. Anlamlılık p≤0,05 düzeyinde değerlendirildi.&#x0D; Bulgular: Ortalama yaşı 37,30±13,86 yıl ve %66 ‘ı (n:196) kadın, %34’ü (n:101) erkek olan 297 hastanın %11,8’inde (n= 35) koronavirus anksiyetesi, %23,2’sinde (n= 69) olası depresyon ve %9,1’inde (n= 27) sosyal medya bağımlılığı izlenmiştir. KAÖ puanı ortalaması 3,06±3,71, PHQ-9 puanı ortalaması 5,13±5,87, BSMBÖ puanı ortalaması 11,15±4,99 saptanmıştır. PHQ-9 puanının sırasıyla KAÖ (p= 0,043; r= 0,118) ve BSMBÖ (p= 0,004; r= 0,166) puanı arttıkça arttığı gözlenmiştir. KAÖ ile BSMBÖ puanları arasında anlamlı bir ilişki gözlenmemiştir (p= 0,525; r= -0,037). Düşük eğitim düzeyinin (ilkokul / ortaokul) KAÖ puanı üzerine 2,7 kat risk arttırıcı (OR= 2,691; C.I.= 1,300-5,571; p= 0,008) etkisi olduğu bulunmuştur.&#x0D; Sonuç: Koronavirus anksiyetesi görülenlerle görülmeyenlerin sosyal medya bağımlılık sıklığının benzer olması, medya kaynaklı artan bilgi maruziyetinde korkulduğu gibi koronavirus anksiyetesinin artmayabileceğini, eğitim düzeyinin asıl risk faktörü olduğunu göstermiştir.

Evaluation of the health literacy level of the patients who applied to a tertiary hospital family medicine clinic

Aim: This study aimed to reveal the level of health literacy of the patients who applied to the family medicine clinic of a tertiary hospital in Turkey and its relationship with demographic parameters.&#x0D; Material and Method: This study is a cross-sectional descriptive study. Study conducted in the family medicine clinic of an education hospital. Demographic characteristics and health literacy levels of the participants such as age, gender, marital status, educational status, professions, and financial status were noted. The health literacy levels of the participants were determined by using the Turkish Health Literacy Scale-32.&#x0D; Results: A total of 443 participants were included in the study. the median age of the participants was 36. The median health literacy of the participants was 33.9 (25th and 75th quartiles: 29.2-40.8). The health literacy index of 57 (12.9%) participants were inadequate 139 (31.4%) participants was problematic, 147 (33.2%) participants were sufficient, and 100 (22.6%) participants was excellent. There was a statistically significant, negative, and weak correlation between age and health literacy index. (r=-0.200, p=0.01, Spearman correlation test).&#x0D; Conclusion: Low health literacy is an important public health problem. Health literacy can be considered a priority policy issue. Legal arrangements can be made to carry out activities for health literacy.

Evaluation of the relationship between lower urinary tract symptoms and fall risks in male patients over 65 years old

Objective. In our study, we aimed to evaluate the relationship between LUTS and fall risk in patients over 65 years old.Methods. 183 people over 65 years old who attended to Health Sciences University Şişli Hamidiye Etfal Training and Research Hospital Family Medicine Polyclinics and Recep Tayyip Erdoğan University Family Medicine Polyclinics between February 2017-May 2017 were included in the study and ‘Individual Presentation Form’ prepared by the researcher questioning socio-demographic characteristics was applied to the participants by face-to-face questioning method, International Prostate Symptom Score (IPSS) and Morse Fall Scale (MFS) were completed afterwards and ROC analysis of IPSS was performed for those who have high risk in terms of MFS. Results. When evaluating the relationship between MFS and IPSS, we observed that as all subscores and total score of IPSS increased, the MFS score increased. The MFS scores of the participants whose IPSS classification was evaluated as severe were found to be significantly higher. ROC analysis of IPSS was performed for those who have high risk in terms of MFS. It was found that area under curve is 78.4%, and those with an IPSS of 13.5 and above show a high fall risk with 71.4% sensitivity and 70% specificity.Conclusions. In our study, we found that as the IPSS of the participants increased, the risk of falling increased. Moreover, we found that age, occupation type, type and number of chronic diseases were effective in both fall and IPSS. In addition to LUTS screening in males, evaluation should be done for the risk of falling.

Clinical Prognosis of Patients With Mild COVID-19 Treated With Casirivimab/Imdevimab in Japan.

Aim: This study aimed to report clinical courses of patients who had mild coronavirus disease 2019 (COVID-19), defined as SpO2 of 96 or higher, and treated with/without casirivimab/imdevimab in Japan, where mortality and number of severe patients were very limited compared to other resource-rich countries.Methods: We conducted a retrospective cohort study in Toyota Regional Medical Center, Toyota, Japan, from August 31, 2021, to September 27, 2021. We included all patients with COVID-19 who were diagnosed at the hospital’s family medicine department. Our primary outcome was admission to the hospital due to COVID-19 and secondary outcome was mortality due to COVID-19. We compared those who received casirivimab/imdevimab and those who did not.Results: A total of 104 patients were included, of whom 30 received casirivimab/imdevimab and 74 did not receive casirivimab/imdevimab. The mean age of the patients was 47.8 ± 15.6 (standard deviation {SD}) years, 57 (54.8%) patients were male. During a median follow-up period of 12 days (interquartile range: 10-16 days), 19 (18.3%) patients were admitted to the hospital and none died. Patients who received casirivimab/imdevimab had similar rate to admission (p = 0.87). The hazard ratio (HR) of admission tended to be lower for those who received casirivimab/imdevimab (HR: 0.76, 95% confidence interval {CI}: 0.23-2.49, p-value = 0.65), but not statistically significant compared to those who did not, after adjusting for age, gender, risk factors, including obesity.Conclusions: Our study demonstrated that patients with COVID-19 had similar disease progression rates regardless of casirivimab/imdevimab administration.

Factors Affecting Blood Pressure Control in Hypertension Patients and Their Social Adaptation

Aim: In this research, we aimed to analyze the factors affecting the control of blood pressure and social adaptation in hypertensive patients. Material and Method: Our study was conducted with 100 hypertensive patients in Ankara Training and Research Hospital Family Medicine Polyclinics between December 2015 and March 2016. Five-day blood pressure follow-up, socio-demographic characteristics and "Fatih Social Tendencies Scale" questionnaire data of the patients were recorded. 5-day blood pressure follow-up of the patients was performed. Results: In our research, physical activity, regular exercise, being on diet, smoking, regular doctor check, medication compliance, marital status, years of education, regular book reading, working status and monthly income were found to be effective in blood pressure control. “Social Adaptation”, “Avoidance of Substance”, “Avoidance of Violence”, “Family Status” and “Economic Status” among social tendency factors were found to be better in patients with blood pressure under control. Conclusion: In blood pressure follow-up, the lifestyle characteristics of the patient should be questioned and taken into consideration. Questioning psychological factors such as social adaptation and providing support through the provision of necessary information and education to the patient will make a great contribution to the patients in terms of blood pressure control.

Are antivirals effective and safe in reducing the duration or severity of symptoms in herpes zoster infection?

1Washington Hospital Family Medicine, Washington, PA 2UPMC St. Margaret Hospital, Pittsburgh, PA The corresponding author is Amy DiPlacido; [email protected] The authors declare no conflicts of interest.

Adult vaccine-related knowledge, attitudes, and behaviors in Turkey.

PurposeAdult vaccination, which is among the duties of family physicians, is an important issue that reduces morbidity and mortality. In this study, it was aimed to evaluate knowledge, attitudes, and behaviors of adults about adult vaccines.Materials and MethodsThis study is a descriptive, cross-sectional research; which was performed by a questionnaire including sociodemographic data and questions about adult vaccination to the patients and their relatives who applied to Şişli Hamidiye Etfal Training and Research Hospital Family Medicine Polyclinics for any reason. Mean, standard deviation and chi-square tests were used for the analysis; p<0.05 was considered significant.ResultsThe study included 182 people, 93 of them were women (51.1%) and 89 (48.9%) were men. The mean age was 32.9±12.8 years; most of them (n=144, 79.1%) were high educated and 38.5% were married. The most known vaccine was tetanus (n=154, 84.6%), the least known was zona vaccine (n=30, 16.5%). Health care professionals and television (n=60, 33%) were the most information sources about vaccines (n=78, 42.9%). Vaccination was mostly (26.9%) recommended by family physicians 144 (79.1%). The students had more knowledge about human papilloma virus (HPV), zoster, and measles, mumps, and rubella vaccines (p≤0.05), and mostly the information was got from internet and school (p≤0.05). As education status increased, knowledge about tetanus, hepatitis A, pneumonia, and HPV vaccines increased significantly, whereas only tetanus vaccination was performed in practice (p≤0.05). As the income increased, knowledge about pneumonia and HPV vaccines increased, but vaccination was not performed as expected.ConclusionAge, occupation, education, and income level are directly related to knowledge and attitudes about adult vaccination. Adult vaccines are still not known and performed enough in Turkey. It is important to encourage and increase the number of trainings via media on this subject.

What is the incidence of behavioral adverse events in adult patients who are treated with levetiracetam?

Providence St. Peter Hospital Family Medicine Residency Program, Olympia, WA The corresponding author is Amanda Bitterman; [email protected]. The authors declare no conflicts of interest.

Evaluation of night eating syndrome in individuals with and without obesity.

There are publications with contrasting results on the relationship between night eating syndrome and obesity. The aim of this study was to investigate the frequency and relationship between night eating syndrome (NES) in obese and non-obese participants. Between 1 January 2018 and 1 May 2018, 420 people ages 18-65 years who applied to İzmir Katip Çelebi University Atatürk Training and Research Hospital Family Medicine and Endocrinology outpatient clinics for any reason enrolled in this study. Body mass index (BMI = weight [kg]/height² [m²]) was calculated by measuring participants' height and weight. BMI values between 18.50 and 24.99 were normal weight, between 25.0 and 29.99 were overweight, between 30.0 and 39.99 were obese, and 40.0 and above were considered morbidly obese. Participants' sociodemographic data, the Night Eating Questionnaire (NEQ), and the Beck Depression Inventory (BDI) were administered by face-to-face interview technique. The average age of the participants was 42 ± 13 years and 68.6% were female. The mean body mass index (BMI) of the participants was 31.8 ± 8.2. The prevalence of NES was determined: 10% of the participants had NES. The higher frequency of NES in patients with morbid obesity was found to be statistically significant compared to those without morbid obesity (p < 0.05). The mean BDS score was 23.5 ± 10.86 (min: 0, max: 46) in the NES group and 12.18 ± 88.95 (min: 0, max: 49) in the non-NES group. There was a significant difference between the two groups in terms of BDS scores (p < 0.001). Because obesity has an important place in primary health care services, it is important to know the relationship between NES and depression. Recognition of NES and consideration of planned follow-up and treatment in the applicants will help to treat obesity more effectively.

Üniversite hastanesi Aile Hekimliği polikliniğinde hasta memnuniyeti ile ilişkili faktörler

Objective: The aim of the study was to evaluate the level of satisfaction of patients over 18 years of age who presented to family medicine outpatient clinic. Methods: The study comprised people over 18 who applied to the Health Sciences University Şişli Hamidiye Etfal Health Practice Research Center (ŞHESUAM) Family Medicine outpatient clinic for any reason and volunteered to participate. Participants were given a 13-question information form prepared considering the literature study. Statistical alpha significance level was accepted p&lt;0.05. Results: The study included 300 participants, 212 (70.7%) female and 88 (29.3%) male. Of the patients, 70% (n=210) were aged between 18 and 40. A statistically significant difference was found between the number of application to outpatient clinic in the last year, having social security and gender. Of the patients, 86.3% (n=259) were satisfied with the health care service offered. Reaching physicians quickly for examination, to be listened carefully by the physician, getting a whole-body examination, being adequately informed about the disease, and believing that enough time was allocated were found to have a statistically significant difference in general satisfaction with the health care. Patients who got whole body examination considered that the prescribed drugs would help them to recover at a higher rate. Participants believing they had enough time reported being appropriately informed by physician at higher rate. Conclusion: Patient satisfaction is influenced by the physician’s language and attitude in his relationship with patient, allocating enough time to the patient and being able to reach physician immediately.