Enhancing the primary care pediatrician's role in managing psychosocial issues: a cross sectional study of pediatricians and parents in Israel.

BACKGROUND: Psychosocial issues are an integral part of children's health and well-being, and it is widely acknowledged that pediatricians should be involved in their management. We examined the current perception of the pediatrician's role in the management of psychosocial problems in Israel from the perspective of parents and pediatricians, and identified possible barriers. METHODS: We assessed parents' and pediatricians' perspectives through a cross sectional survey. 1000 parents with children under 10 were randomly selected from a large database representing the Israeli population and phone-surveyed by a polling company. Due to a low response-rate (5.4%), there was an overrepresentation of married parents and underrepresentation of parents with primary or secondary education. 173 Pediatricians were recruited both at a medical conference and by a web-based questionnaire. RESULTS: 55% of the parents reported they were concerned with at least one psychosocial problem, yet less than 50% of them discussed these issues with the pediatrician. 59.9% of the parents did not perceive psychosocial problems as relevant to the pediatrician's role. Pediatricians with some previous training related to psychosocial issues were more likely to report on a lack of professional confidence (p = .037) and insufficient available resources (p = .022) as barriers to their involvement, while pediatricians who had no training were more likely to report on the parents' perception of their role as the barrier to involvement (p = .035). CONCLUSIONS: Parents tend to avoid the discussion of psychosocial concerns in pediatric settings due to their perception that it's irrelevant to the pediatrician's role. Trained pediatricians feel unconfident in their ability to manage psychosocial issues and report on a lack of suitable resources. These findings suggest current pediatric mental-health training is insufficient to equip pediatricians with the knowledge and skills required to their involvement in psychosocial problems, and imply necessary changes to environment of community-based pediatrics. In order to change the practice of pediatricians in the community to enable them to address a variety of psychological issues, appropriate training is needed, through all stages of the pediatrician's professional life, including medical school, pediatric residency and continuous medical education.

[COMMUNITY PEDIATRICS IN ISRAEL DURING THE NEXT DECADE - A NEED FOR A CHANGE].

INTRODUCTION: Community pediatrics in Israel is based on service by pediatricians who have been trained in hospitals in Israel or elsewhere. At the same time, the field of community pediatrics is changing its nature from the management of common acute diseases, to a field dealing with a variety of chronic problems, behavioral issues, family and social issues, developmental delays, problems relating to nutrition and growth' sleep problems, learning disabilities, and of late, excessive exposure to a host of digital media. In addition, lifestyle issues such as adequate physical activity, addictions, accidents and various types of abuse are increasingly part of the pediatric role. The hospital-based residency training of pediatricians does not offer the future pediatrician the opportunity to learn these elements of the "New Morbidity". As a result, many community-based pediatricians choose not to confront these problems, and either ignore them or refer them to various consultants outside of the clinic. The entire health system, including the Ministry of Health, the Israel Medical Association, the medical schools, the health service providers (Kupot Holim) and the hospitals must cooperate in changing the format of residency training, both undergraduate and residency. This is required in order to create a new generation of pediatricians who are better equipped to deal with the increasing number of children needing help with the above-mentioned pathology. Advancing the field of primary care pediatrics by attending to these New Morbidity issues, together with pediatric involvement in community agencies, after appropriate training, will improve the health and development of the child population, together with improvement of their physical, emotional and social welfare.

On the track to adulthood: the missions of the young human being, dodging the risks and gaining the tools.

Medical staff are expected to cooperate with other professions and agencies in helping the young human in achieving the goal of becoming a healthy, well- functioning adult that expresses her/his maximal potential. Achieving this goal should be cost-effective. Cost includes not just the economic burden but also psychosocial determinants such as emotional disruption, stress, living at risk, malfunctioning, and dependency. Acknowledging the risks and the expected achievements at each age are useful in analyzing the failure of community health programs and in planning preventive modalities and needed remedies.

Should we consider alternatives to universal well-child behavioral-developmental screening?

The prevalence of developmental disabilities in the young age is of the order of 15%. When behavioral and social-emotional disorders, physical impairments, and sensory disorders are included, the need for special intervention increases to one out of four children. As the sensitivity and specificity of the best screening tests are in the range of 70-80%, their predictive value is controversial. The cost of conducting definitive tests and repeat screening for those who fail the screening tests is high. Children with severe disorders can be identified clinically without a screening test. The poor predictability, difficulty in implementation, and the high costs of developmental testing suggest that children, particularly those in high-risk communities, might be better served by implementing intervention programs for all, instead of trying to identify the outliers through screening.

Physicians' ability to influence the life-style behaviors of diabetic patients: implications for social work.

Diabetes is aggravated by a sedentary lifestyle, obesity and smoking. Based on a theoretical model relating attitudes and behavior, this study examined the association between physicians' self efficacy in counseling diabetic patients on life style behaviors and their counseling practices. Data were gathered from a representative sample of 743 primary care physicians in Israel's two largest health plans. The main findings were that only a small percentage of physicians felt capable of influencing their patients' life-style behaviors. Self-efficacy had an independent effect on the likelihood of counseling diabetic patients on life style behaviors, controlling for other background variables. We conclude that there is a need for enhancing physicians' life-style counseling skills, and that social workers could expand their role by training physicians to counsel effectively. This could both improve the care of diabetic patients, and strengthen the status of the social work profession in the healthcare system.