Burnout in Israeli medical students: a national survey.

INTRODUCTION: Professional burnout is characterized by loss of enthusiasm for work, cynicism, and a low sense of personal efficacy. Burnout may adversely affect medical professionalism. Burnout is common in clinicians and varying rates have been reported in medical students. No data exist regarding the prevalence of burnout among Israeli medical students. The aims of this study were to assess the rate of burnout in Israeli medical students and to identify students who were particularly susceptible to burnout. METHODS: A cross-sectional questionnaire design was employed, gathering data from medical students in all years of study across three medical schools. Burnout was measured using the Maslach Burnout Inventory Student Survey (MBI-SS), translated into Hebrew. RESULTS: Of the 2160 students in the participating medical schools, 966 (44.7%) completed MBI-SS and demographic questionnaires. The overall burnout rate was 50.6%. Multivariate logistic regression analysis yielded that female gender, age under 25, advanced year of study, studying at a specific medical school and not being a parent are all significantly correlated with higher levels of burnout. CONCLUSIONS: A high rate of burnout was found. The identification of young women who are not parents during advanced years of studies as being at-risk is important, in order to guide the development of burnout prevention interventions.

Common Laboratory Parameters for Differentiating Between Community-Acquired and Healthcare-Associated Pneumonia.

BACKGROUND AND OBJECTIVES: The correct diagnosis of healthcare-associated pneumonia (HCAP) as opposed to community-acquired pneumonia is essential for the selection of a correct empirical antimicrobial approach, reserving the broad-spectrum or highly potent antimicrobial therapies for resistant strains most commonly present in HCAP, whereas treating the less resistant strains, most commonly associated with community and long-term care facility-acquired infections, with a more targeted empirical approach. The standard approach today is to differentiate between the two based on the medical history of the past 90 days prior to admission. Measurable, quantitative assessment may be able to assist in this decision. The objective of this study is to find a measurable method of differentiating between community-acquired and healthcare-associated pneumonias. MATERIALS AND METHODS: The records of 126 patients admitted with a diagnosis of pneumonia were divided into two groups based on the probable cause of their disease, in accordance with common practice. The routine laboratory work taken upon admittance was analyzed using logistical regression and Student's t-test. RESULTS: We have found that the red blood cell distribution width and the neutrophil-to-lymphocyte ratio, both routine parameters obtained in a simple blood count, can each assist in differentiating between community-acquired and healthcare-associated pneumonias. CONCLUSION: We have found two statistically significant parameters that may be used as adjuncts to the medical history, chest radiography and other parameters in forming an immediate clinical impression of a patient presenting with pneumonia.

Parents reported higher satisfaction rates when children recognised hospital staff from photographs placed in prominent locations.

AIM: Improved communication with staff during a child's hospitalisation is an important determinant of family satisfaction. We examined whether displaying staff photographs in prominent locations would help children and their parents or guardians to recognise staff and whether this enhanced identification would improve parental satisfaction with their child's hospitalisation. METHODS: No photographs were displayed during the first part of the study. During the second part of the study, staff photographs were placed in prominent locations throughout the paediatric ward. Parents filled in a satisfaction questionnaire on discharge, and the children and their parents were asked how many staff members they could name. RESULTS: The children named a significantly larger number of staff members in phase two than phase one, while the parents' score was unchanged. Overall parental satisfaction was significantly higher in phase two. The parent's age, the duration of the child's hospitalisation and taking part in phase two of the study were significant predictors of parental satisfaction. CONCLUSION: When children were more able to recognise and name hospital staff, this indirectly improved parental satisfaction, even if the number that parents could identify remained unchanged. Displaying staff photographs is a simple way of increasing parental satisfaction during a child's hospitalisation.

More than visual literacy: art and the enhancement of tolerance for ambiguity and empathy.

BACKGROUND: Comfort with ambiguity, mostly associated with the acceptance of multiple meanings, is a core characteristic of successful clinicians. Yet past studies indicate that medical students and junior physicians feel uncomfortable with ambiguity. Visual Thinking Strategies (VTS) is a pedagogic approach involving discussions of art works and deciphering the different possible meanings entailed in them. However, the contribution of art to the possible enhancement of the tolerance for ambiguity among medical students has not yet been adequately investigated. We aimed to offer a novel perspective on the effect of art, as it is experienced through VTS, on medical students' tolerance of ambiguity and its possible relation to empathy. METHODS: Quantitative method utilizing a short survey administered after an interactive VTS session conducted within mandatory medical humanities course for first-year medical students. The intervention consisted of a 90-min session in the form of a combined lecture and interactive discussions about art images. The VTS session and survey were filled by 67 students in two consecutive rounds of first-year students. RESULTS: 67% of the respondents thought that the intervention contributed to their acceptance of multiple possible meanings, 52% thought their visual observation ability was enhanced and 34% thought that their ability to feel the sufferings of other was being enhanced. Statistically significant moderate-to-high correlations were found between the contribution to ambiguity tolerance and contribution to empathy (0.528-0.744; p ≤ 0.01). CONCLUSIONS: Art may contribute especially to the development of medical students' tolerance of ambiguity, also related to the enhancement of empathy. The potential contribution of visual art works used in VTS to the enhancement of tolerance for ambiguity and empathy is explained based on relevant literature regarding the embeddedness of ambiguity within art works, coupled with reference to John Dewey's theory of learning. Given the situational nature of the tolerance for ambiguity in this context, VTS provides a path for enhancing ambiguity tolerance that is less conditioned by character traits. Moreover, the modest form of VTS we utilized, not requesting a significant alteration in the pre-clinical curricula, suggests that enhancing the tolerance of ambiguity and empathy among medical students may be particularly feasible.

Correction to: More than visual literacy: art and the enhancement of tolerance for ambiguity and empathy.

CORRECTION: Following publication of the original article [1], the authors reported that the corrections they had requested for Table 3 had not been implemented, and that the title for Table 2 included an unnecessary indication for remark/reference ("a" in a superscript font) at the end of the title. Also, the affiliation of the authors had not been clearly stated: it should read 'Faculty of Medicine, Bar-Ilan University, Safed Campus, P.O.Box 1589, Safed, Israel'.

Pre-procedural Ultrasonography for Tracheostomy in Critically Ill Patients: A Prospective Study.

BACKGROUND: Percutaneous dilatational tracheostomy (PDT) has become a standard technique for critically ill patients who require long-term ventilation. The most common early post-operative complication is bleeding related to anatomical variation in vasculature. The procedure is performed at the patient's bedside unless this is deemed unsafe and then the accepted alternative is open tracheostomy in the operating room. OBJECTIVES: To evaluate the use of pre-procedural ultrasound to aid in the decision of whether PDT in critical care patients should be performed at the patient's bedside or by open surgical tracheostomy. METHODS: Patients were jointly evaluated by a critical care physician and a head and neck surgeon. Based on this evaluation, the method of tracheostomy was determined. Subsequently, pre-procedural ultrasound examination of the anterior neck was performed. The final decision whether to perform PDT or open surgical tracheostomy was based on the ultrasound findings. Changes in management decisions following ultrasound were recorded. RESULTS: We included 36 patients in this prospective study. Following ultrasound examination, the management decision was changed in nine patients (25%). CONCLUSIONS: Pre-procedural ultrasound for critically ill patients undergoing tracheostomy can influence management decisions regarding the performance of tracheostomy.

The Dedicated Enough Doctor: The Limits of Medical Altruism in the 21st Century.

BACKGROUND: The unique characteristics of the next generation of medical professionals in Israel and the current model of physician employment in the country may pose a real threat to the high quality of both public clinical care and medical education in the near future, and to the continued flourishing of clinical research. According to the Israel Medical Association's general obligations for Israeli physicians, the doctor should place the patient's interests foremost in his or her mind, before any other issue. This has led many to believe that selflessness or altruism should be among a physician's core values. Is the application and realization of these obligations compatible with the realities of 21st century medicine? Is altruism still a legitimate part of the modern medical world? The Y generation, those born in the 1980s and 1990s, now comprise the majority of the population of residents and young specialists. They have been characterized as ambitious, self-focused, entrepreneurial, lacking loyalty to their employer, and seeking immediate gratification. Under these circumstances, is it possible to encourage or even teach altruism in medical school? Demands on physicians' time are increasing. The shortage of doctors, the growth of the population, the way in which health care is consumed, and the increasing administrative burden have all gnawed away at the time available for individual patient care. This time needs to be protected. The altruism of physicians could become the guarantee of first-rate care in the public sector. The continued existence of clinical research and high level clinical teaching also depends on the allocation of protected time. In light of the emerging generation gap and the expected dominance of Y generation physicians in the medical workforce in the near future, for whom altruism may not be such an obvious value, solutions to these predicaments are discussed.

[DR. ARIEH LEIB SHIMONI-MEKLER - EYE, EAR, NOSE AND THROAT SPECIALIST].

Although the inauguration of the new hospital in Zefat built by Baron Rothschild took place in 1910, the building was not used as a hospital until World War I when it was confiscated by the Turks for patients affected with typhus, and later it was converted into a military hospital. The second inauguration of the renewed hospital was in June 1919, and the medical activity was assigned to the American Zionist Medical Unit for Palestine' (AZMU), later - 'Hadassah Medical Organization'. Among the first doctors that were sent to Zefat by AZMU was Dr. Arieh Leib Shimoni-Mekler - Eye, Ear, Nose and Throat specialist. Dr. Shimoni-Mekler worked in the hospital during the years 1921-2.

Acupuncture for posttonsillectomy pain in children: a randomized, controlled study.

BACKGROUND: Surgeons have searched for the technique or medication that will produce a 'painless tonsillectomy'; however, this seems to be an impossible goal. Previous studies have shown that perioperative acupuncture may be a useful adjunct for acute postoperative pain and that acupuncture, in addition to nonsteroidal anti-inflammatory drugs, is effective in adults for the treatment of postoperative swallowing pain after tonsillectomy. Acupuncture has been shown to be safe in children. A retrospective review of acupuncture for posttonsillectomy pain in juvenile patients showed a significantly reduced pain score immediately after treatment. AIM: To examine whether acupuncture, in addition to conventional analgesic treatment, will be effective in the treatment of posttonsillectomy pain in children. METHODS: We conducted a randomized, controlled, single-blinded study comparing conventional postoperative analgesic treatment with the same regime plus acupuncture to assess whether postoperative treatment of children aged 3-12 years undergoing tonsillectomy with acupuncture will reduce pain and to examine possible unwanted effects of this treatment. RESULTS: Sixty children were recruited and randomly divided into a study group and a control group. The results indicate that in the study group, there was less pain, less analgesic drug consumption, and higher patient/parent satisfaction with analgesic treatment scores. No adverse effects were recorded. CONCLUSIONS: Acupuncture, in addition to conventional analgesic treatment, is an effective treatment for posttonsillectomy pain. Acupuncture is safe and well received by children and their parents.

Fatal complications of percutaneous dilatational tracheostomy.

OBJECTIVES: Fatal complications of percutaneous dilatational tracheostomy (PDT) are rare and intraoperative fatal complications of PDT even more so. We present the unique case of a fatal nonvascular intraoperative complication of PDT, previously unreported in the medical literature. We also present a review of all previously reported fatal complications of PDT. METHODS: A review of all previously reported fatal complications of PDT was conducted in order to examine the prevalent causes of death and to attempt to recommend measures designed to prevent similar fatal complications in the future. RESULTS: Cases of death during or following PDT in which the technique is related to the cause of death have only been reported in a small number of cases. Almost all fatal complications of PDT result from vascular injury. CONCLUSIONS: Any vascular pulsation palpated over the tracheostomy site mandates preoperative ultrasound or conversion to open surgical tracheostomy. Patients with previous neck surgery, radiotherapy or unclear surgical anatomy should be regarded with caution. If a difficult intubation or a difficult procedure is anticipated, it may be preferable not to attempt PDT with a plan to convert to surgical tracheostomy if necessary but instead to perform surgical tracheostomy without attempting PDT.

Remote penetrating orbital trauma due to a snooker cue through the mouth.

PURPOSE: This is a unique case report of a self-inflicted orbital injury that presented as a simple upper vestibulum laceration. A 43-year-old man presented to the Oral and Maxillofacial Surgery Unit with a small laceration in his mouth and complaints of pain in his left eye due to a snooker cue penetration. Upon admission, clinical findings included a small laceration on the upper left vestibulum and a subdermal hematoma in the left eye lid with restricted movements of the left eye. Further examination revealed remote trauma to the orbit, penetrating through the oral cavity, passing the maxillary sinus, and the orbital floor causing traumatic optic neuropathy with partial visual loss. The patient was treated conservatively with antibiotics and corticosteroids and a 6-week follow up. CONCLUSION: In cases of remote penetrating injury, meticulous examination revealing precise injury mechanism is crucial. All cases of Dento-maxillofacial trauma should include a high degree of clinical suspicion for ocular injury, requiring early diagnosis and treatment to reduce risk of visual loss.

Big Data for Biomedical Education with a Focus on the COVID-19 Era: An Integrative Review of the Literature.

Medical education refers to education and training delivered to medical students in order to become a practitioner. In recent decades, medicine has been radically transformed by scientific and computational/digital advances-including the introduction of new information and communication technologies, the discovery of DNA, and the birth of genomics and post-genomics super-specialties (transcriptomics, proteomics, interactomics, and metabolomics/metabonomics, among others)-which contribute to the generation of an unprecedented amount of data, so-called 'big data'. While these are well-studied in fields such as medical research and methodology, translational medicine, and clinical practice, they remain overlooked and understudied in the field of medical education. For this purpose, we carried out an integrative review of the literature. Twenty-nine studies were retrieved and synthesized in the present review. Included studies were published between 2012 and 2021. Eleven studies were performed in North America: specifically, nine were conducted in the USA and two studies in Canada. Six studies were carried out in Europe: two in France, two in Germany, one in Italy, and one in several European countries. One additional study was conducted in China. Eight papers were commentaries/theoretical or perspective articles, while five were designed as a case study. Five investigations exploited large databases and datasets, while five additional studies were surveys. Two papers employed visual data analytical/data mining techniques. Finally, other two papers were technical papers, describing the development of software, computational tools and/or learning environments/platforms, while two additional studies were literature reviews (one of which being systematic and bibliometric).The following nine sub-topics could be identified: (I) knowledge and awareness of big data among medical students; (II) difficulties and challenges in integrating and implementing big data teaching into the medical syllabus; (III) exploiting big data to review, improve and enhance medical school curriculum; (IV) exploiting big data to monitor the effectiveness of web-based learning environments among medical students; (V) exploiting big data to capture the determinants and signatures of successful academic performance and counteract/prevent drop-out; (VI) exploiting big data to promote equity, inclusion, and diversity; (VII) exploiting big data to enhance integrity and ethics, avoiding plagiarism and duplication rate; (VIII) empowering medical students, improving and enhancing medical practice; and, (IX) exploiting big data in continuous medical education and learning. These sub-themes were subsequently grouped in the following four major themes/topics: namely, (I) big data and medical curricula; (II) big data and medical academic performance; (III) big data and societal/bioethical issues in biomedical education; and (IV) big data and medical career. Despite the increasing importance of big data in biomedicine, current medical curricula and syllabuses appear inadequate to prepare future medical professionals and practitioners that can leverage on big data in their daily clinical practice. Challenges in integrating, incorporating, and implementing big data teaching into medical school need to be overcome to facilitate the training of the next generation of medical professionals. Finally, in the present integrative review, state-of-art and future potential uses of big data in the field of biomedical discussion are envisaged, with a focus on the still ongoing "Coronavirus Disease 2019" (COVID-19) pandemic, which has been acting as a catalyst for innovation and digitalization.

Monothermal caloric testing in the screening of vestibular function.

INTRODUCTION: The alternate binaural bithermal caloric test (ABBT) is the standard test for evaluation of the dizzy patient. Monothermal caloric testing (MT) has the potential benefits of reducing the administration time and patient discomfort. The goal of the present study was to investigate the role of MT screening in the prediction of ABBT results. METHODS: ABBT results of 218 patients having normal otoneurological examination, normal hearing, and normal electronystagmography (ENG) were retrospectively analyzed to generate norms for all subtests. These norms were then employed to calculate the sensitivity and specificity of MT for predicting normal ABBT in a group of 197 consecutive dizzy patients who were referred for vestibular testing. RESULTS: The best predictions of ABBT by MT results were achieved when ENG testing showed oculomotor integrity and no spontaneous, positional, or positioning nystagmus. Under these conditions, warm MT lateralization < 32% had 90% sensitivity and 92% specificity for the prediction of normal ABBT. DISCUSSION: When no pathology is detected in the other parts of the ENG, warm MT lateralization < 32% can indicate normal ABBT with a 10% probability for a false-negative result. This false negative rate precludes the routine use of warm MT in the clinical realm and its application as a screening tool for possible vestibular deficits in a generally healthy population like aviation or diving candidates. Higher sensitivity may be achieved by lowering the cut-off point of the response asymmetry required for the diagnosis of MT screening failure and the omission of directional preponderance diagnosis from the goals of the screening.

Harmonic scalpel tonsillectomy using the curved shears instrument versus cold dissection tonsillectomy: a retrospective study.

OBJECTIVES: We compared operating time, intraoperative blood loss, and rate of postoperative bleeding in harmonic scalpel (HS) tonsillectomy using the curved shears instrument to those in cold dissection (CD) tonsillectomy. METHODS: The charts of 560 patients who underwent tonsillectomy were retrospectively reviewed. Three hundred nineteen patients underwent CD tonsillectomy between the years 1998 and 1999, and 241 patients underwent HS tonsillectomy using the curved shears instrument between the years 2001 and 2005. For the purpose of evaluation of postoperative bleeding rates, the groups were further stratified by age (11 years of age or less versus 12 years of age or more). RESULTS: For the HS group, the mean operating time was shorter (7 minutes versus 17.57 minutes) and the intraoperative blood loss was lower (0 mL versus 42.12 mL). These differences were statistically significant (p < .05). There was no significant difference in the overall postoperative bleeding rates between the two groups. The postoperative bleeding rate in the HS patients 11 years of age or younger was lower than that in the equivalent age group in the CD group (0.56% versus 2%, respectively), although this difference did not reach statistical significance. The postoperative bleeding rate in the HS patients 12 years of age or older was significantly higher than that in the equivalent age group in the CD group (7.93% versus 1%, respectively; p < .05). CONCLUSIONS: Harmonic scalpel tonsillectomy using the curved shears instrument offers advantages over CD tonsillectomy regarding operating time and intraoperative blood loss. In our patients more than 12 years of age, HS tonsillectomy using the curved shears instrument was associated with an increased postoperative bleeding rate compared to CD tonsillectomy.

Acute myopericarditis complicating acute tonsillitis: beware the young male patient with tonsillitis complaining of chest pain.

OBJECTIVES: We describe 11 cases of myopericarditis complicating bacterial tonsillitis. METHODS: We performed a retrospective study of all cases of myopericarditis treated at one hospital during the years 2005 and 2006. RESULTS: The patients were all young men. The average latency from the onset of throat pain to the onset of chest pain was 4.6 days. All patients complained of chest pain. The most common electrocardiographic finding was transient ST segment elevations. The levels of cardiac enzymes and troponin were elevated in all cases. CONCLUSIONS: Otolaryngologists should be aware of this rare entity. Additional studies are indicated to evaluate the exact incidence of myopericarditis associated with acute streptococcal tonsillitis.

[Occult peritonsillar abscess: an unusual cause of unilateral tonsillar enlargement].

Peritonsillar abscess is a suppurative infection of the tissues adjacent to the palatine tonsil and is regarded in otolarygologic practice as a complication of pharyngotonsillitis. The most common presentation is gradually increasing pain, fever, trismus, drooling and a muffled voice. Asymmetric tonsils are common in clinical practice. Differential diagnosis includes infectious, granulomatous, congenital and neoplastic lesions. This is a case study of two patients evaluated for unilateral tonsillar enlargement who were found to have a previously unexpected peritonsillar abscess at tonsillectomy. The patients had no other signs or symptoms of acute pharyngotonsillar or peritonsillar infection. To our knowledge, this is the first report of an occult peritonsillar infection causing unilateral tonsillar enlargement.

Mobile Technology-Based Real-Time Teleotolaryngology Care Facilitated by a Nonotolaryngologist Physician in an Adult Population.

OBJECTIVES: Telehealth can improve access to specialist care. Very few reports of the use of smartphones for teleotolaryngology exist. The objective of this study is to evaluate the use of mobile teleotolaryngology facilitated by a nonotolaryngologist physician. METHODS: A prospective study in adult patients attending a general otolaryngology outpatient clinic. The telehealth encounter with a remote otolaryngologist was facilitated by a final-year medical student simulating a general physician prior to the scheduled visit. The patient and the remote otolaryngologist rated their satisfaction with the encounter. The remote otolaryngologist formulated a diagnosis and rated the level of certainty of this diagnosis. Diagnoses from the telehealth encounter and the face-to-face encounter were compared. RESULTS: Forty-eight patients with an average age of 42.5 years participated in this study. In 79.2% of the consultations, there was concordance between the diagnoses. The average patient and remote otolaryngologist satisfaction with the encounter was 9.5 ± 0.9 and 8.7 ± 1.3, respectively. Twenty-four of the 48 visits (50%) were defined as unnecessary. In the otology group, concordance rates and rates of preventable visits were highest. CONCLUSIONS: Synchronous telehealth consultations, facilitated by a general physician, can be an alternative to visiting a general otolaryngology clinic, especially for otologic patients.

Nasal septal perforation repair using oral mucosal flaps.

BACKGROUND: Surgery for the closure of nasal septal perforations is challenging. Numerous techniques have been described. OBJECTIVES: To assess whether nasal septal perforations heal less consistently if a connective tissue scaffold is not placed between the repaired septal flaps. METHODS: We performed closure of a septal perforation via a closed approach using oral mucosal flaps without the interposition of a connective tissue graft in seven patients. RESULTS: Complete perforation closure was achieved in 5 cases (71.4%). There was no significant donor site morbidity. CONCLUSIONS: These initial results suggest that this is an effective technique for closing nasal septal perforations; it obviates the morbidity of the open approach and the added operating time and morbidity associated with the harvesting of a connective tissue graft.