Examining professional boundaries between nurses and physicians in neonatal intensive care units.

BACKGROUND: Medical and technological developments, financial constraints and a shortage of physicians have made it necessary to re-examine professional boundaries between physicians and nurses. Israel's manpower shortage in Neonatal Intensive Care Units (NICUs) has changed the responsibility and authority of nurses. However, these changes have not evolved into a uniform policy defining the division of responsibility between physicians and nurses. This study was designed to examine the work processes and actual division of labor between NICU physicians and nurses; the attitude of physicians and nurses to greater empowerment of the nursing role; and to suggest a model to regulate work processes and develop the role of neonatal nurse specialists in NICUs. METHODS: Open interviews with NICU physician-directors and head nurses and a cross-sectional survey of some 50% of the physicians and nurses at 22 hospital NICUs (N = 430). RESULTS: Main problems of NICUs: physician shortage, deficient infrastructures, fragmented work processes. Nurses do not perform many practices allowed to them due to the need for organizational approval and their own unawareness. Conversely, they sometimes conduct procedures and make decisions outside of their authority. Most physicians agree that nurse graduates of Post-Basic Education training (PBE) should be authorized to independently perform such activities as resuscitation and medication balancing while reserving invasive procedures for physicians. It is widely agreed that broadening the authority of nurses would improve the quality of NICU care even though it would increase the nursing workload. CONCLUSIONS: The study provides important input into decisions about authorizing nurses over complete practice areas rather than isolated activities; the need to remove institutional restrictions on tasks currently permitted to nurses; introducing teamwork from within the NICUs, and expanding nursing decision-making. The study reveals that there is a basis on which to to build the role of the neonatal nurse,since most NICU nurses have the suitable academic and clinical training.

Work satisfaction, quality of life, and leisure time of neonatology fellows and senior neonatologists in Israel.

OBJECTIVES: To examine work satisfaction, quality of life, and leisure time of neonatology fellows and senior neonatologists in Israel. METHODS: A validated questionnaire was delivered during the second half of 2008 to all the neonatology fellows and senior neonatologists in Israel. Descriptive analysis, parametric Student's t-test, and aparametric Mann Whitney and χ2 tests were conducted. RESULTS: Of 114 practicing neonatologists in that period in Israel (including both seniors and fellows), 112 (98.25%) participated in the study. The majority of neonatologists were male (53.2%), married (91.7%), 40-60 years old (69.7%), and studied in Israeli medical schools (62.0%). Most did their pediatric residencies and fellowships in Israel (97.2% and 75.7%, respectively). The average number of night/on-call shifts of fellows and senior neonatologists was 8.8 per month (SD ± 3.425) and the number of active on-call shifts was 4.04 (SD ± 3.194). The satisfaction level of neonatologists in Israeli medical centers with patient care, self-reward, work relations, and quality of life was high, but their satisfaction level with workload, income and prestige, and leisure time was low. The general index of work satisfaction and the general index of indices were both high in relation to the mid-range values. The majority of neonatologists stated that they would choose to practice medicine again. Most of them would encourage medical students to choose the same specialty they had chosen. Only a few neonatologists were contemplating changing their choice of specialty. Most neonatologists want to continue practicing medicine; however, a significant number will not recommend that their children do so. CONCLUSIONS: The satisfaction level of neonatologists in Israel is high, mainly due to satisfaction with their work. High satisfaction levels promise high quality patient care, as well as high satisfaction levels of patients and their families. However, satisfaction with leisure time was low and it will require greater attention and focused steps to correct this.

A model for assessing the gap between physician residency demand and present status.

BACKGROUND: The medical workforce shortage worldwide varies for different residencies. OBJECTIVES: To determine future gaps in medical specialties in Israel by means of a model and to identify trends and considerations among medical students when they choose their residencies. METHODS: The gap (Gi) assessment model was based upon current demand (Di) and existing (Ei) status for each residency, using the formula [Gi = (Di-Ei)/Ei]. Ei represented the proportion of specific residencies in 2006-2010 out of all Israeli residency graduates and Di was based on questionnaires filled out by medical students at Sackler and Hadassah medical schools in Tel Aviv and Jerusalem, respectively (N = 909). RESULTS: The largest relative shortages (Gi ranges from -1 to 1) were in Pathology (G = -1), Rehabilitation Medicine (-0.9), Radiology (-0.8), Family Medicine (-0.8) and Anesthesiology (-0.8). The highest relative demands were in Surgical subspecialties (2.9) and Obstetrics/Gynecology (OB/GYN) (1.6). More females than males chose residencies in OB/GYN (19.5% vs. 7.1%, P < 0.001) and Pediatrics (28.1% vs. 15.4%, P < 0.001). Surgery subspecialties (9% vs. 23.7%, P < 0.001) were male-predominant. The workload consideration was rated higher among females, while income was rated higher among males. Among students in clinical years, compared to pre-clinical, there was a decline in the selection of some professions, including Surgical subspecialties (9.7% vs. 19.5%, P < 0.001). CONCLUSIONS: The suggested model, based on a survey of demand and current or projected future needs, can be used to assess gaps and plan early interventions. Programs at the level of medical school may affect residency preferences. The decline in selection of surgical professions and the increasing workload as a consideration for residency choice should be given attention.

[Obstetrics and gynecology workforce planning: the Israeli experience 1995-2025].

BACKGROUND: Currently, there is no current obstetricians and gynecologists' workforce (OBGW) planning in Israel. Forecasting the OBGW is a challenge in order to achieve optimal obstetrics and gynecology care in the next decades. OBJECTIVE: To examine the current Israeli OBGW and to describe, using an equation, the future supply of OBGW, until 2025. METHODS: A descriptive study of past (1995-2006) and future (through 2025) OBGW trends in Israel. An equation was developed to project physician supply until 2025. RESULTS: No "optimal ratio" exists regarding OBGW to female population ratio. In addition, information regarding OBGW planning is scarce. In Israel, the ratio of OBGW aged < 65 years per 1000 females aged > or = 15 years, was 0.35 in 2006, 23% more than the higher projected ratio from USA for 2005. In 2020, for comparison, the ratio in Israel will be 18% higher than the US ratio. The ratio calculated by the equation presents a plateau of the supply of Ob-Gyn specialists in Israel until 2025. A continued significant growth in the number of Ob-Gyn female specialists, compared with males, is noted. The interpretation of this data requires further evaluation. CONCLUSIONS: In order to preserve the quality of care, there is a need for continuous monitoring and structured planning of health care human resources and OBGW in particular. Research and data in this field are scarce and, therefore, there is a need to conduct many additional research studies. Furthermore, additional data collection is needed to evaluate quality of care and its availability according to the relation between manpower needs and expected demands in Israel's health system.

[The approach to the physician shortage in Israel].

The practice of medicine has changed in the last decade. Physicians no longer work largely solo but are part of interdisciplinary medical teams, and patient cases are more complex, as they suffer from multiple diseases. Today, the physician must also deal with economic, legal and public opinion issues. All of these factors pose new challenges to physicians. Apart from the changing world, there is also a shortage of physicians in Israel, as the number of new immigrant physicians has decreased over the last decade. Other medical professions and infrastructures are also lacking, including nurses, acute care hospital beds, intensive care beds and more. This increases the burden on physicians who must face a rapid turnover of patients per bed, more than in any other OECD country. In our work, we have suggested some new approaches to the physician shortage, apart from increasing the number of positions in medical schools, including changing the residency program and canceling the internship. The residency program will be divided into two stages: Two years in general medicine surgery or pediatrics and the second part in subspecialties such as pediatric surgery, neurology, gastroenterology, cardiology and others. An option to continue residency in general medicine, pediatrics, or surgery will also be possible and must be encouraged. We believe that the Scientific Council of the Israeli Medical Association is the professional organization that must evaluate this proposition.

Yield of recommended blood tests for neonates requiring phototherapy for hyperbilirubinemia.

BACKGROUND: Hyperbilirubinemia of the newborn is common. Rarely is an underlying disease other than physiologic hyperbilirubinemia considered the cause of high bilirubin levels. Some of the laboratory tests recommended by the American Academy of Pediatrics are expensive and do not always lead to diagnosis. OBJECTIVE: To evaluate the efficacy of standard laboratory tests performed on newborn infants requiring phototherapy for hyperbilirubinaemia. METHODS: We conducted a retrospective chart review that included neonates born during a 6 month period with birth weight 2500 g treated with phototherapy for hyperbilirubinemia (n = 282) according to published guidelines. The main outcome measures were primary and maximal bilirubin values (mg/dl), time to jaundice (in days), the number of bilirubin tests undertaken and whether the patient showed abnormal functioning, and the number of days in follow-up. RESULTS: Thirty-three neonates (11.7%) were positive in at least one laboratory test (defined as "Abnormal" in our study), 45.5% of whom met the criteria for phototherapy during the first 48 hours of life. Among the newborns who were negative for all laboratory tests (defined as "Normal"), only 6.8% met phototherapy criteria within their first 48 hours of life (P < 0.001). In the Normal group there was a consistent decrease in total serum bilirubin values shortly after phototherapy was begun, while the Abnormal group presented an increase in serum bilirubin values during the first 12 hours of phototherapy. None of the infants had conjugated (direct) hyperbilirubinemia during the study period. CONCLUSIONS: Most neonates presenting with a laboratory identifiable etiology for hyperbilirubinemia (i.e., hemolysis) can be distinguished from those who test negative, mainly based on the timing of presentation and response to phototherapy. A more meticulous selection of patients and reduction in the magnitude of routine laboratory testing can safely reduce discomfort to infants with hyperbilirubinemia as well as costs.

A report card on the physician work force: Israeli health care market--past experience and future prospects.

BACKGROUND: The worldwide shortage of physicians is due not only to the lack of physicians, but also to complex social and economic factors that vary from country to country. OBJECTIVE: To describe the results of physician workforce planning in a system with unintended policy, such as Israel, based on past experience and predicted future trends, between 1995 and 2020. METHODS: A descriptive study of past (1995-2009) and future (through 2020) physician workforce trends in Israel. An actuarial equation was developed to project physician supply until 2020. RESULTS: In Israel a physician shortage is expected in the very near future. This finding is the result of global as well as local changes affecting the supply of physicians: change in immigration pattern, gender effect, population growth, and transparency of data on demand for physicians. These are universal factors affecting manpower planning in most industrial countries all over the world. CONCLUSION: We describe a health care market with an unintended physician workforce policy. Sharing decision makers' experience in similar health care systems will enable the development of better indices to analyze, by comparison, effective physician manpower planning processes, worldwide.

Cesarean section and the risk of fractured femur.

BACKGROUND: The rate of cesarean section is increasing and in the United States recently exceeded 30% of all deliveries. Birth injuries during CS are relatively rare. Femur fractures have a very low incidence during both vaginal delivery and CS. OBJECTIVES: To assess our 10 year experience (2008-1997) in managing fractured femur during CS, including a typical case. METHODS: We reviewed the prevalence of femur fractures in two tertiary, academic, level one trauma center hospitals in Israel (Hadassah in Jerusalem and Soroka in Beer Sheva). RESULTS: During the study period 221,939 deliveries occurred in both hospitals. Of these, 17.6% were cesarean sections (38,990 CS). Of the total number of deliveries, the incidence of femur fracture was 0.077 per 1000 deliveries (17 fractures), and the incidence of femur fracture during CS was 0.308 per 1000 CS (12 fractures). CONCLUSIONS: Cesarean section increases the risk of femur fractures (P < 0.001) with an odds ratio of 11.26 (confidence interval 3.97-31.97).

[Work satisfaction, quality of life and leisure time of residents at the Soroka University Medical Center, Beer Sheba, Israel].

BACKGROUND: Work dissatisfaction among physicians worldwide continues to rise over the last few decades, mainly due to declining professional prestige, tack of self fulfillment, time pressure and tack of leisure time. Physicians' burnout is a major result of dissatisfaction, causing doctors to leave the medical profession, and to provide lower quality of care. OBJECTIVES: To examine the work satisfaction, quality of life and leisure time of residents in the Soroka University Medical Center. METHODS: A validated questionnaire was delivered during the second half of 2004 to 252 residents in the Soroka University Medical Center The data was analyzed using the SPSS 12 for windows program. Descriptive analysis, parametric Students' T Test [where p<0.05 was set to be considered valid) and a-parametric Mann Whitney and x2 tests were conducted. RESULTS: A total of 137 residents responded to the questionnaire (response rate of 54.36%]. The residents' satisfaction level was low, mainly due to dissatisfaction with their quality of life. There was no difference in satisfaction between male and female residents. Residents in the early stage of their internship were more satisfied than residents who had completed the first stage in regard to their income (p=0.005). Surgical residents were less satisfied than non-surgical residents (p=0.003), mainly from the work relations with their superiors (p=0.015). CONCLUSIONS: The residents at the Soroka University Medical Center were satisfied with their work environment but not with their quality of life and leisure time. Further attention must be given to these matters--a step which will eventually improve patient care, and delay, to some extent, the burnout of physicians.

[Medical tourism: changing a world trend into a national resource].

Medical tourism is a new world trend that has great potential. Many countries, especially in the Far East, invest in this emerging industry in order to build a modern medical infrastructure that will attract foreigners and will create a new source of income, while improving the medical services provided to the local community. This article reviews relevant Literature and recent research on medical tourism. We suggest that israel adopt a health policy that will use local know-how to turn it into a world leader in medical tourism.

Doctor, is my teddy bear okay? The "Teddy Bear Hospital" as a method to reduce children's fear of hospitalization.

BACKGROUND: Children report various types of fear in the context of hospitalization, such as fear of separation from the family, having injections and blood tests, staying in the hospital for a long time, and being told "bad news" about their health. OBJECTIVES: To examine the effects of the "Teddy Bear Hospital" method on preschool children's fear of future hospitalization. METHODS: The study group comprised 41 preschool children aged 3-6.5 years (mean 5.1 +/- 0.7 years), and 50 preschool children, age matched and from a similar residential area, served as the control group. Assessment included a simple one-item visual analog scale of anxiety about hospitalization. This was assessed individually one day prior to the intervention and again a week after the intervention in both groups. RESULTS: While baseline levels of anxiety were not different between groups [t(89) = 0.4, NS], children in the "Teddy Bear Hospital" group reported significantly lower levels of anxiety than the control group at follow-up. CONCLUSIONS: Our results indicate that by initiating a controlled pain-free encounter with the medical environment in the form of a "Teddy Bear Hospital", we can reduce children's anxiety about hospitalization.

[Medical students' knowledge and attitudes towards costs of tests and treatments].

OBJECTIVES: 1) To examine medical students' knowledge about costs of laboratory tests, imaging procedures, and treatments. 2) To examine medical students' attitudes regarding receiving information about costs, and its effect on their future clinical behavior. DESIGN: This was a cross-sectional study using an anonymous three-part questionnaire that was distributed to all students of the Ben Gurion University Medical School. Responses were received from 269 students (approximately 70%). RESULTS: According to the results, most students did not estimate the costs correctly. It was found that: 69.5% of the students did not receive any information about costs during their studies; 81.4% of the students expressed interest in receiving such information; 66.2% thought that knowing the costs would change their future clinical decision making. CONCLUSIONS AND RECOMMENDATIONS: Medical students lack information regarding the cost of laboratory tests and medical treatments. Providing information to medical students about costs may help reduce future health care expenses. Our recommendations are: 1. To include economic content in the medical curriculum; 2. To perform periodic updates and continuing medical education in this area; 3. To combine this educational program with other intervention methods in order to effectively reduce health care expenses.

[Interns: the relationship between sleep deprivation, working hours and performance].

In recent years numerous studies were published on the relationship between working hours, sleep deprivation and medical errors, clinical judgement, attention and motor vehicle accidents. This article reviews the latest literature on interns and the implications of continuous working hours, without sleep. Current policy changes in the realm of working hours and rest, both in Israel and throughout the world, are reviewed.

Clinical guidelines, defensive medicine, and the physician between the two.

PURPOSE: In this article, we study the use of the American Academy of Otolaryngology-Head and Neck Surgery recommendations regarding coagulation screening tests before tonsillectomy and adenoidectomy by ear, nose, and throat (ENT) physicians in Israel and offer insights into the reasons for accepting/declining this recommendation. MATERIALS AND METHODS: During April and May 2002, 309 self-administered questionnaires were sent to all ENT physician members of the Israeli Society of Otolaryngology-Head and Neck Surgery. Physicians answered questions regarding demographic data, their habits of preoperative laboratory and imaging tests before tonsillectomy and adenoidectomy, and the reasons for performing these tests. RESULTS: One hundred ninety-six (63.4% compliance rate) physicians responded to the survey. One hundred fifty-four (78.6% of the responding physicians) do not follow guideline recommendations and ask their otherwise healthy patients to undergo prothrombin time/partial thromboplastin time (PT/PTT) tests before tonsillectomy and adenoidectomy. Common practice in their departments was the leading reasoning for preoperative PT/PTT testing for 101 (51.5%) physicians. Eighty-nine physicians (45.4%) specifically stated that the reason for this behavior is defensive medicine, thirty-two physicians (16.3%) stated that the reason for those tests is hospital requirements, and literature recommendation was the reason in 24 (12.2%), followed by personal experience for 11 physicians (5.6%). CONCLUSIONS: Most ENT physicians in Israel do not follow clinical guidelines and perform unnecessary coagulation tests before tonsillectomy and adenoidectomy. More studies are needed to find ways to change physicians' behavior regarding preoperative tests.

Teaching medical students what they think they already know.

OBJECTIVES: To discuss the problems encountered teaching interviewing skills to first year medical students and describe their responses to a structured workshop in interviewing skills. METHODS: Focus groups and a short evaluation questionnaire filled in by 56 first year medical students before and after a workshop in interviewing skills were used. RESULTS: All students evaluated their skills very highly prior to the workshop. After participating in the workshop, students evaluated their skills as lower than before. DISCUSSION: When communication skills are taught in an informal, unstructured manner, medical students might view this knowledge as unspecialized, repetitive, and even boring. It is suggested that employing a structured model for teaching doctor-patient communication skills awards psycho-social issues the status of formal knowledge. This can lead to students viewing communication skills as a relevant and consistent body of knowledge. Introducing a structured model can overcome two kinds of problems: over-confident students are formally introduced to unique aspects of medical interviewing, whilst those who lack confidence are offered a lifeline in the form of a structured model. Identifying possible sources of resistance to communications training has important implications for medical education as it allows for appropriate course planning and follow up.

Reasons for overprescription of mononitrates: the paradigm of stable angina pectoris treatment.

BACKGROUND: Oral nitrates, beta-blockers, and calcium channel blockers are used to treat stable angina pectoris (SAP). The 2 therapeutic subtypes of oral nitrates are mononitrates and dinitrates, with no evidence that 1 subtype is more efficacious than the other. Although practice guidelines in Great Britain and Israel recommend dinitrates as the first-line drug for SAP, in practice, many physicians in those 2 countries prescribe mononitrates. OBJECTIVE: The aim of this study was to identify factors that influence specialist physicians (family practitioners, internists, and cardiologists) in Israel when prescribing nitrates for the prevention of SAP symptoms. METHODS: A group of specialists was given a self-administered questionnaire regarding their treatment of choice for a patient with SAP described in a hypothetical case vignette. End points for prescribing preferences were evidence-based information, cost, and the influence of pharmaceutical company representatives. RESULTS: One hundred ten specialists were given the questionnaire. Eighty-nine specialists (45 men, 44 women; mean age, 50.4 years; range, 34-67 years; response rate, 80.9%) completed it (39 family practitioners, 29 internists, and 21 cardiologists). Seventy-eight respondents (87.6%) chose to prescribe nitrates for the case vignette, and among those, 54 (69.2%) chose mononitrates and 24 (30.8%) chose dinitrates (P = 0.034). The choice of mononitrates over dinitrates was mainly affected by habit (25/54 [46.3%]) and the belief that mononitrates are more effective, safer, and/or less expensive than dinitrates (21/54 [38.9%]). Drug costs for the patient significantly influenced more family practitioners than hospital specialists (P<0.05). CONCLUSIONS: In contrast to guideline recommendations, the paradigm of SAP treatment with nitrates in this study was characterized by significantly more prescriptions for mononitrates than dinitrates. This situation contributes to the erosion of the scarce resources of the health care system in Israel. Further efforts are needed to increase physicians' awareness of quality, cost, and choices when prescribing drugs.

Role of a medical students' association in improving the curriculum at a faculty of health sciences.

The Joyce and Irving Goldman School of Medicine, Faculty of Health Sciences at the Ben Gurion University of the Negev encourages students to take part in the development and evaluation of the teaching experience. These special relations between the school and the students contribute not only to changes in the curriculum but also to increased involvement of faculty and students in the community. This article reviews the special relationship between the Faculty of Health Sciences and its medical students through the Medical Students Association (ASRN). During the last decade, BGU medical students have initiated innovative programmes some of which have recently become integrated into the curriculum. These include: prevention of sexual violence among youth, decreasing white-coat fear in small children ('Teddy Bear hospital') and participation in home-hospice activities. By encouraging students to become equal partners in faculty development and rejecting the traditional paternalistic mode of teacher-student relationships, the faculty has created an improved learning experience, and increased student motivation and levels of communication between the teachers and the future clinicians.