Adolescent health care education and training: insights from Israel.

There is a growing need for health care professionals to extend their knowledge in adolescent health care. Formal training curricula in adolescent medicine have been established in the United States, Canada, and Australia, yet many other countries have developed shorter training programs to enable interested physicians to further pursue knowledge and practical experience in delivering improved quality health care for adolescents. The Israeli experience in building an infrastructure that allows students and physicians to learn about adolescent medicine and to train in the field is described. It includes a series of lectures and seminars for medical students during medical school and at the clinical rotations in pediatric wards; the development of hospital-based and community-based multidisciplinary adolescent health services where residents can practice adolescent health care; a 3-year diploma course in adolescent medicine for specialists in pediatrics and family medicine; mini courses in adolescent medicine for pediatricians and family practitioners working in community settings; and a simulated patient-based program regarding communication with adolescents, aimed for all professional levels - medical students, residents, and specialists. This infrastructure has been developed to create a leading group of physicians, who are able to operate adolescent clinics and to teach adolescent medicine. Recently, a formal fellowship program in adolescent medicine has been approved by the Scientific Council of the Israel Medical Association. The Israeli experience described here could be applied in countries, where formal training programs in adolescent health care are not yet established.

Training Physicians toward a Dignifying Approach in Adolescents' Health Care: A Promising Simulation-Based Medical Education Program.

BACKGROUND: Human dignity has a pivotal role within the health care system. There is little experience using simulation-based medical education (SBME) programs that focus on human dignity issues in doctor-patient relationships. OBJECTIVES: To describe and assess a SBME program aimed at improving physicians' competence in a dignifying approach when encountering adolescents and their parents. METHODS: A total of 97 physicians participated in 8 one-day SMBE workshops that included 7 scenarios of typical adolescent health care dilemmas. These issues could be resolved if the physician used an appropriate dignifying approach toward the patient and the parents. Debriefing discussions were based on video recordings of the scenarios. The effect of the workshops on participants' approach to adolescent health care was assessed by a feedback questionnaire and on 5-point Likert score questionnaires administered before the workshop and 3 months after. RESULTS: All participants completed both the pre-workshop and the feedback questionnaires and 41 (42%) completed the post-workshop questionnaire 3 months later. Practice and competence topics received significantly higher scores in post-workshop questionnaires (P < 0.001). A score of high to very high was given by 90% of physicians to the contribution of the workshop to participants understanding the dignifying approach, and by 70% to its influence on their communicative skills. CONCLUSIONS: A one-day simulation-based workshop may improve physicians' communication skills and sense of competence in addressing adolescents' health care issues which require a dignifying approach toward both the adolescent patients and their parents. This dignity-focused methodology may be expanded to improve communication skills of physicians from various disciplines.

Empowering adolescents to control alcohol-associated risky situations.

BACKGROUND: Alcohol consumption among youth is a major public health problem due to its association with negative outcomes which are generally preventable. Schools can play an important role in increasing health knowledge and promoting healthy behaviours that can reduce alcohol-associated risks. This paper describes and evaluates an innovative experiential project that aims to augment existing alcohol high school educational programmes. METHODS: Students of 11th grade classes, age 16-17 years, participated in a one-school-day programme which included: a lecture on alcohol related risks; an enacted scenario of violent behaviour related to alcohol use; meeting with a disabled person injured in an alcohol-associated road accident, and discussion of two video movies regarding consequences of excessive alcohol drinking. The students filled a preintervention alcohol-related knowledge, attitude and practice questionnaire, a feedback questionnaire at the end of the one-day programme, and a 3-months postintervention questionnaire on their alcohol-related behaviours. RESULTS: 665 eleventh grade students participated in the project. The preintervention questionnaire revealed adequate knowledge on alcohol-related risks by 65% of the students. The feedback questionnaire revealed that most students felt that the programme added to their knowledge and that it might change their alcohol use behaviour. The postintervention questionnaire filled by 195 students revealed that 81% would not refrain from alcohol drinking following the project; however 47% reported consuming alcohol in moderation, and 24% specified decrease in the amount of alcoholic beverages. CONCLUSIONS: An experiential educational programme regarding negative outcomes of alcohol consumption resulted in reported alcohol-related behaviour change in a proportion of high school students.

[Adolescents ask physicians on the Internet: a one-year survey of adolescents' questions on health issues in an Internet forum].

INTRODUCTION: During the past decade, the internet has become a major information resource in various domains of life and a communication venue among young people and adolescents who seek health information via the internet. Until now, the contents of Israeli adolescents' questions regarding health issues on internet sites have not been published. PURPOSES: (1) A survey of the characteristics of adolescents who seek health information and their questions presented to the Ynet forum "The body during adolescence". In this forum physicians experienced in adolescent medicine respond to these questions and to comments of other forum participants. (2) Presentation of problematic issues in professionals' responses to health questions in the internet. METHODS: Survey of a representative sample of contacts to the Ynet forum "The body during adolescence" during 2009 gathering information on gender and age of contacting person, parents' contacts, contacts' contents and physicians responses. RESULTS: A total of 412 contacts were surveyed, 210 (51%) females, aged 14-17 years--60%, 10-13 years--17% and 18-21 years 15%. Parents' questions appeared in 39 (9%) of contacts. Of all contacts, 44% related to sexuality issues and 17% related to self image and body composition. The physicians provided complete responses to 60% of the contacts, while in 40% the physician's responses included referral to clinical medical consultation. CONCLUSIONS: An internet health forum enables adolescents and parents to ask questions and raise doubts and anxieties regarding various health issues without the fear of being exposed and enables them to express their concerns face-to-face with a healthcare provider Sensitive issues regarding sexuality and self-image, which are not raised frequently during clinical encounters, are expressed and receive professional responses in the forum. Notwithstanding the significance of a rapid professional contribution, physicians responding to contacts in internet forums need to recognize the barrier related to professional communication with persons whom they have not met and for whom follow-up is impossible.

[Simulated-patient-based educational programs for improvement of physicians' communication skills with adolescents: 7-years experience at the Israel Center For Medical Simulation].

BACKGROUND: Appropriate communication between healthcare providers and adolescent patients and their parents is the key for successful medical care that recognizes the unique needs of teenagers, who remain their parents' responsibility but deserve individual attention separately. Guidelines addressing adolescents' healthcare have been developed, and include recommendations for appropriate communication with adolescents. Simulated-patient-based education has become a significant tool for improving communication skills of heaLthcare providers. OBJECTIVE: To describe the experience gained at the Israel Center for Medical Simulation (MSRJ during the past 7 years in communication training for physicians who encounter adolescents in their cLinical practice. METHODS: Simulated-patient-based communication workshops were conducted dedicated to physicians who provide healthcare to adolescents. Eight to twelve physicians participated in each workshop, where 8 scenarios were exercised from a pooL of 20 typical scenarios of adolescent-physician encounters that have been prepared at MSR. The participants completed a feedback questionnaire at the end of each workshop regarding its quality, its contribution and its value as an educational tool. RESULTS: Five hundred physicians--pediatricians, family practitioners, gynecologists and military recruitment centers physicians--were trained in simulated-patient-based workshops on communication with adolescents between the years 2002 and 2008. Feedback questionnaires of 470 physicians completed at the end of 41 workshops were surveyed. High ranks were given to all the evaluation issues in the questionnaire. CONCLUSIONS: Training physicians in communication with adolescents at simulated-patient-based workshops is a powerful educational tool, enabling hands-on Learning and application of communication skills. These workshops are highly appreciated and recommended by the participating physicians as useful mechanisms in various medical education Levels.

Effect of a simulated patient-based educational program on the quality of medical encounters at military recruitment centers.

BACKGROUND: Simulation-based medical education has become a powerful tool in improving the quality of care provided by health professionals. OBJECTIVES: To evaluate the effect of a simulated patient-based educational program for military recruitment center physicians on the quality of medical encounters with adolescent candidates for military service. METHODS: Twelve physicians participated in an educational intervention that included a one day SP-based workshop, where simulations of eight typical candidates for military service were conducted. Assessment of the physicians' performance before and after the intervention was based on questionnaires filled by 697 and 508 military candidates respectively upon completion of their medical examination by these physicians. The questionnaire explored health topics raised by the examining physician as well as the atmosphere during the encounter. The candidates were also asked whether they had omitted important medical information during the medical encounter. RESULTS: Pre- and post-intervention comparison revealed significant changes in the percentages of candidates who reported that they had been asked questions related to psychosocial topics: school problems--59.7% and 68.9% (P = 0.01), protected sex--29.6% and 36.4% (P = 0.01), mood changes--46.9% and 52.2% (P = 0.05) respectively. Physicians were perceived as being interested in the candidates by 68.2% of the candidates before the intervention and 77.5% after (P < 0.01). The percentage of candidates who reported omitting medical information decreased from 6.6% before the intervention to 2.4% after (P < 0.01). CONCLUSIONS: A simulated patient-based educational program for military physicians improved the quality of physician-candidate encounters. Such programs may serve as an effective instrument for training physicians to communicate with adolescents.

A simulated patient-based program for training gynecologists in communication with adolescent girls presenting with gynecological problems.

Most gynecologists lack the unique skills required for communication with female adolescent patients and with their parents. Years of clinical experience are required to develop communication skills that would facilitate the confidence of the young patient already during the first visit. Simulation-based medical education at the Israel Center for Medical Simulation (MSR) has become a powerful force in quality-care training for healthcare providers using empirical educational modalities, enabling controlled proactive experiential exposure to both regular and complex scenarios. Among the various MSR programs, for various medical sectors, training programs have been developed to improve the skills of physicians communicating with adolescents, including primary care physicians and school doctors. This paper describes the first reported simulated patient-based MSR training program for gynecologists in communication with adolescents who present with common complaints encountered in gynecology clinics. Twenty gynecologists participated in eight individual simulated scenarios conducted at simulated physicians' offices, equipped with audio-visual recording cameras and one-way mirrors for observation. Three physicians experienced in debriefing and in facilitating group discussions led the debriefing sessions, using the video recording of the simulated scenario following the simulation exercises. These discussions focused on communication techniques when facing adolescent patients with or without their parents, hidden agendas disclosed by using systematic physical and psychosocial reviews, the emotional load often associated with clinical problems, and the non-judgmental and supportive approach to adolescent patients. The clear recommendation that emerged from the high satisfaction of the program participants was to expand simulated patient-based programs for gynecologists and to include it as an integrated part of the training curriculum in pediatric and adolescent gynecology.

Recurrent abdominal pain before and after appendectomy.

BACKGROUND: Patients with non-inflamed appendix have been reported to have had more hospitalizations and emotional disorders before and after the operation than patients with acute appendicitis. OBJECTIVES: To compare abdominal pain characteristics, as well as demographic and psychosocial data in children with histologically confirmed appendicitis compared to non-inflamed appendices. METHODS: Charts of children with suspected appendicitis who had undergone appendectomy were retrospectively reviewed for relevant clinical and laboratory data. The patients or their parents were then contacted by phone and were asked to respond to a detailed questionnaire on abdominal symptoms as well as demographic and psychosocial data. RESULTS: The study group comprised 156 children: 117 with histologically confirmed appendicitis and 39 with normal appendices. Eighty-two patients (53.2%) were located and interviewed: 62 (54%) with appendicitis and 20 (51%) with normal appendices. Of the 82 children, 16 reported recurrent episodes of abdominal pain before or after surgery: 11 (17.7%) in the appendicitis group and 5 (25%) in the normal appendix group. Only six patients fulfilled the formal criteria for the diagnosis of recurrent abdominal pain: 5 (8%) from the appendicitis group and 1 (5%) from the non-inflamed appendix group (not significant). In addition, no significant statistical differences were found between the groups regarding school performance, behavior and social interaction with peers. CONCLUSIONS: We could not demonstrate an increased incidence of recurrent abdominal pain, nor could we identify significant psychosocial morbidity in those children undergoing an appendectomy for a non-inflamed appendix.

Assessment of health issues and concerns of Israeli seventh graders during school physician examinations: a pilot study.

BACKGROUND: The AMA Guidelines for Adolescent Preventive Services (GAPS) recommends annual medical evaluations during adolescence, emphasizing screening and counseling regarding psychosocial issues. In Israel, seventh graders undergo medical examinations within the school health services, focusing on the detection of physical conditions. We addressed the psychosocial issues of these students by introducing an expanded school physician evaluation. METHODS: Twelve school physicians performed structured expanded health evaluations for seventh graders in 11 schools. Each student completed a questionnaire (checklist) with 22 health topics "about which s/he may want to receive information." The physician then carried out a biomedical and psychosocial evaluation, physical examination, and offered counseling to the student. RESULTS: Two hundred and seventy-eight students were examined. The questionnaire required 1-2 minutes, and the physician's evaluation 20-25 minutes. Health behaviors revealed included: currently dieting (28%), no physical activity after school (35%), ever smoked cigarettes (3%), ever smoked a water pipe (9%), used alcoholic beverages (6%), and does not always use front (22%) or rear (55%) seat belt. Nine percent rated their mood as being less than 7 (on a scale from 1 to 10). The leading topics about which the students requested information were height (50%), acne (42%), weight (38%), nutrition/diet (37%), physical activity (35%), and menstrual period (29% of the girls). The physicians counseled the students on an average of 3.6 topics per visit. CONCLUSIONS: An expanded school physician examination identifies students with psychosocial problems otherwise undetected during standard physical examinations, and provides the opportunity to address their personal concerns.

Preferences of Israeli adolescents in regard to health services: a pilot study.

This pilot study surveyed Israeli adolescents' preferences regarding health services as a preliminary step for a national survey. A total of 444 students filled a questionnaire including demographics, personal health data, and preferences regarding 31 statements on health care, based on a Philadelphia questionnaire. Factors of most significant impact in seeking health care were cleanliness, integrity, respectfulness, knowledge, and competence. The 10 top statements important to Israeli teens included 9 of the 11 top statements of the Philadelphia teens. Future research may demonstrate change in outcome if adolescents' desires were attended based on a cultural adapted questionnaire.

Health perspectives regarding adolescents in military service.

PURPOSE OF REVIEW: Our purpose is to illuminate health perspectives of adolescents in military service, who comprise the main bulk of military personnel. RECENT FINDINGS: Two views are emphasized: the soldier as a developing adolescent and the healthcare of adolescent soldiers. The capacity for abstract thinking and future planning, characteristic of late adolescence, opposes the military challenges of obedience, disengagement from the family, and potential threats for physical injury and mental stress, in addition to the requirement for responsibility beyond the individual's personal needs. On the other hand, at discharge from military service, the mature young adult faces questions of a 17-year-old adolescent. Health perspectives regarding adolescents in military service include physical and mental health screening before draft; recruiting adolescents with chronic illnesses; specific healthcare issues during service, including routine medical care, psychosocial problems of young people in service and approach to suicide and to risk behaviors; health aspects of adolescent women in military frameworks; and the dual commitment of physicians as military officers. SUMMARY: Professionals who care for the well-being of young people in their late teens and early 20s in military service need to consider the service period as an additional developmental stage within late adolescence that requires attention as part of the comprehensive healthcare.

Emotional and behavioral outcomes among adolescents with mild developmental deficits in early childhood.

PURPOSES: To evaluate emotional and behavioral outcomes in adolescents who in early childhood were treated for mild developmental deficits; and to identify predictive factors in early childhood, for future emotional and social competence abnormalities. METHODS: The records of children referred to Hanna Khoushi Child Development Center in Haifa for mild developmental delay were reviewed. Parents and adolescents were requested to complete the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR) 12 to 16 years after discharge from the Child Development Center. Analysis of the two questionnaires and identification of predictive variables in early childhood for emotional problems and social competence difficulties during adolescence were performed, using ANOVA Student's T-test, Chi-square, and multiple regression. RESULTS: The most frequent developmental diagnoses on admission to the Child Development Center were mild motor (27.3%) or language (23.2%) deficits. Of the treated children, 53.4% were discharged without any developmental deficit. All CBCL and YSR T-scores were within the nonpsychopathology range. No notable differences were found between the study scores and the scores regarding typical Israeli and American youths. Significant differences were, however, observed in self-perception of internalizing emotional problems between male and female adolescents: T-scores of 51.9 +/- 8.0 vs. 47.4 +/- 10.8, respectively (p < .05). Motor and language deficits were associated with lower general competence than general developmental delay and emotional developmental disturbances (T-scores: 47.9 vs. 49.1 and 50.9, p< .05). Admission to the Center after the age of 18 months was associated with higher T-scores for general as well as externalizing problems when compared with scores associated with admission before the age of 18 months (by 5.75 points for both parameters, p < .001). CONCLUSION: The perception of parents and children with minor developmental deficits observed in early childhood regarding their emotional and social competence during adolescence is similar to typical youths.

[Development and assessment of simulated patient based curricular unit in order to improve clinical skills in adolescent medicine of pediatric and family practice residents].

OBJECTIVE: This study describes the development and evaluation of a curricular program aimed at improving the clinical and communication skills required for managing the clinical encounter with adolescents, among pediatric and family practice residents using the technique of standardized patients. METHODS: A daylong curricular unit which included: clinical interviews with simulated patients presenting typical clinical problems occurring among adolescents; a teaching unit explaining the principles of communication with adolescents and a clinical discussion and feedback session using video clips. Forty-eight residents in pediatrics and family practice undertook the curricular unit. A total of 120 doctor-simulated patient interviews were documented using six patients' case scenarios representing somatization disorder, eating disorder, chronic illness and non-compliance, pregnancy, drug abuse and menstrual disorder. RESULTS: The doctors' self-estimation of clinical skills associated with adolescent medicine that was documented at the beginning of the curricular unit was generally reported as low. In most of the cases the participants did not identify the main problem and diagnoses that were presented. The problems least correctly diagnosed were eating disorder and non-compliant chronic illness. Only in the cases of somatization and pregnancy more than half of the residents identified the problems that were presented. At the end of the curricular unit the doctors expressed a very high level of satisfaction with the program. CONCLUSION: The present study developed and evaluated a short and structured curricular unit dealing with the principles of communication with adolescent patients using the technique of simulated/standardized patients. It was found that the lack in these skills, which was identified in pediatric and family practice residents, could be bridged using this educational technique.

Adolescent medicine with a 100 year perspective.

Adolescent medicine was born out of scientific advances from a wide variety of disciplines, changes in societal mores and the explosion of technology that occurred during the 20th century. The past 100 years of clinical practice and research have provided a wealth of information that has improved our understanding of the biologic and physical development of adolescents as well as the epidemiology of high-risk adolescent behaviors. The present challenge for all providers of health care to adolescents is to continue to examine the effect of these high-risk behaviors and develop mechanisms to address and limit the impact of these behaviors, just as the scientists and practitioners of the 20th century made great strides in treatment and cure of medical illnesses. With a broad base of scientific knowledge, formalization into an academic field and strong government and organizational support adolescent medicine are energized by these factors and can only envision continued growth in this important field of medicine.