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.

Perceptions of Practicing Physicians and Members of the Public on the Attributes of a "Good Doctor".

Since physician-patient relationships are a central part of the medical practice, it is essential to understand whether physicians and the general public share the same perspective on traits defining a "good doctor". Our study compared the perceptions of physicians and members of the public on the essential traits of a "good doctor." We conducted parallel surveys of 1000 practicing specialist-physicians, and 500 members of the public in Israel. Respondents were asked about the two most important attributes of a "good doctor" and whether they thought the physicians' role was to reduce health disparities. Many physicians (56%) and members of the public (48%) reported that the role of physicians includes helping to reduce health disparities. Physicians emphasized the importance of non-technical skills such as humaneness and concern for patients as important traits of a "good doctor," while the public emphasized professional and technical skills. Internal medicine physicians were more likely than surgeons to emphasize humaneness, empathy, and professionalism. Future research should focus on actionable approaches to bridge the gap in the perceptions between the groups, and that may support the formation of caring physicians embedded in a complex array of relationships within clinical and community contexts.

Nurturing a Society of Learners: Suggestions from Traditional Jewish Pedagogy for Medical Education.

Historically speaking, in many societies a select few carried the burden of preserving and transferring knowledge. While modern society has broadened the scope of education, this is not enough in the medical sciences. We must ensure that all those who pursue a career in medicine become life-long learners who will grow and contribute well beyond their years in medical school. In considering how to attain this goal, we were intrigued by the similarities between generations-old wisdom of teaching and learning methods in Jewish culture and modern educational principles. Both aim to nurture a culture of learners. Our objective was to parallel the methodologies, pedagogic directives, and demands made of students in the Jewish tradition, to the principles used in medical education today. We surveyed the traditional Jewish culture of teaching and learning. We compared it to modern medical teaching methods and looked to see what lessons might be gleaned. In the traditional Jewish community, life is focused on education, and producing "learners" is the ideal. This culture of learning was developed over the generations and many educational methods are similar to modern ones. Some of the pedagogic principles developed successfully in Jewish society should be considered for adaptation in medical education. Further comparative research could help to expand the ways in which we teach medicine.

Maternal and child health in Israel: building lives.

Israel is home to a child-oriented society that values strong family ties, universal child benefits, and free education for all children from 3 years of age to school grade 12. Alongside the universal health-care services that are guaranteed by the National Health Insurance Law and strong, community-based primary and preventive care services, these values have resulted in good maternal and child health. In 2015, infant and maternal mortality (3·1 deaths per 1000 livebirths and 2·0 deaths per 100 000 livebirths, respectively) were lower than the mean infant and maternal mortality of countries within the Organisation for Economic Co-operation and Development. Israel has already exceeded the developed regions' Sustainable Development Goal 2030 targets for maternal mortality, neonatal mortality, and mortality in children younger than 5 years in all population groups. Yet these accomplishments are marred by Israel's high prevalence of child poverty (more than 30%), particularly among Arabs (63%) and ultra-Orthodox Jews (67%). Although infant mortality has improved in all subpopulations since Israel was founded in 1948, infant mortality among Arabs is still more than twice as high as among Jews. To address these disparities in health, the Israeli Ministry of Health has created a special division and has funded an intervention programme to reduce the infant mortality among Bedouin Arabs. Other interventions include targeted and culturally appropriate health-care programmes and services for communities with a high number of at-risk children and young adults, dental health service for all children up to 15 years, and improved collaboration between health, education, and welfare services. The challenges faced by the Israeli health-care system include a growing trend towards medicalisation of prenatal care, ensuring staff are trained to treat developmental, behavioural, and psychosocial issues in children and their families, securing sustainable funding for health promotion and injury prevention programmes, expanding and improving the coordination of services for children with special needs or who are at risk, and programme assessment. Ensuring adequate funding for dedicated, preventive paediatric care and taking action on a nationwide scale to reduce child poverty are essential for maintaining health gains in children. In this Series paper, we describe the health indices, highlight disparities, and discuss the challenges in delivering and maintaining maternal and child health care in Israel.

Medical education in Israel 2016: five medical schools in a period of transition.

ABSTRACT: We reviewed the existing programs for basic medical education (BME) in Israel as well as their output, since they are in a phase of reassessment and transition. The transition has been informed, in part, by evaluation in 2014 by an International Review Committee (IRC). The review is followed by an analysis of its implications as well as the emergent roadmap for the future. The review documents a trend of modernizing, humanizing, and professionalizing Israeli medical education in general, and BME in particular, independently in each of the medical schools. Suggested improvements include an increased emphasis on interactive learner-centered rather than frontal teaching formats, clinical simulation, interprofessional training, and establishment of a national medical training forum for faculty development. In addition, collaboration should be enhanced between medical educators and health care providers, and among the medical schools themselves. The five schools admitted about 730 Israeli students in 2015, doubling admissions from 2000. In 2014, the number of new licenses, including those awarded to Israeli international medical graduates (IMGs), surpassed for the first time in more than a decade the estimated need for 1100 new physicians annually. About 60 % of the licenses awarded in 2015 were to IMGs. CONCLUSIONS: Israeli BME is undergoing continuous positive changes, was supplied with a roadmap for even further improvement by the IRC, and has doubled its output of graduates. The numbers of both Israeli graduates and IMGs are higher than estimated previously and may address the historically projected physician shortage. However, it is not clear whether the majority of newly licensed physicians, who were trained abroad, have benefited from similar recent improvements in medical education similar to those benefiting graduates of the Israeli medical schools, nor is it certain that they will benefit from the further improvements that have recently been recommended for the Israeli medical schools. Inspired by the IRC report, this overview of programs and the updated physician manpower data, we hope the synergy between all stakeholders is enhanced to address the combined medical education quality enhancement and output challenge.

Promoting resiliency for interprofessional faculty and senior medical students: Outcomes of a workshop using mind-body medicine and interactive reflective writing.

BACKGROUND: Health care professions faculty/practitioners/students are at risk for stress and burnout, impacting well-being, and optimal patient care. AIMS: We conducted a unique intervention: an interprofessional, experiential, skills-based workshop (IESW) combining two approaches: mind-body medicine skills and interactive reflective writing (RW) fostering self-awareness, self-discovery, reflection, and meaning-making, potentially preventing/attenuating burnout and promoting resiliency. METHODS: Medical and nursing faculty and senior medical students (N = 16) participated in a 2-hour workshop and completed (1) Professional Quality of Life measure (ProQOL) and (2) a questionnaire evaluating understanding of professional burnout and resiliency and perceived being prepared to apply workshop techniques. Thematic analyses of anonymized RWs exploring meaningful clinical or teaching experiences were conducted. RESULTS: Participants reported better understanding of professional burnout/resiliency and felt better prepared to use meditation and RW as coping tools. RW themes identified experiencing/grappling with a spectrum of emotions (positive and negative) as well as challenge and triumph within clinical and teaching experiences as professionally meaningful. CONCLUSIONS: Positive outcomes were obtained within a synergistic resiliency skills building exercise. Successful implementation of this IESW provides good rationale for studying impact of this intervention over a longer period of time, especially in populations with high rates of stress and burnout.

[NEWBORN DISCHARGE LETTER AS A COMMUNICATION DOCUMENT FOR CONTINUITY OF CARE].

AIMS: To check information items in newborn discharge letters from various delivery rooms and compare them to the expectations of community pediatricians. BACKGROUND: The newborn discharge letter is the document that supports the transition of care from the hospital stay to life at home and in the community. It usually summarizes medical information related to the baby's family, maternal pregnancies, delivery and the stay in hospital until discharge. It is primarily a communication tool between healthcare professionals. It is also a legal document that records basic anthropomorphic and physiologic measurements. METHODS: A comparison of items in discharge letters and a survey among pediatricians. RESULTS: A survey of 104 community pediatricians revealed that the most important information that is expected to appear in a discharge letter includes duration of pregnancy, mode of delivery, APGAR score, birth weight, head circumference, weight at the time of discharge, and the results of hearing screening test and red reflex in the examination of the eyes. Except for the red reflex, all this information appears in the discharge letters of the 19 hospital delivery centers that were checked. Items of information that were rated less important for the community pediatricians were history of previous pregnancies, maternal blood type, time of delivery, baby's length and size of the fontanelle. Inconsistency in the presentation of information in discharge letters was the major concern indicated by community pediatricians. There was a major difference between hospitals with regard to the detailing of instructions to parents about the baby's safety, feeding, and further follow-up in the community. CONCLUSIONS: It is desirable that newborn discharge letters from different hospitals will have more uniformity and more detailed information.

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.

Parental opinions and level of knowledge regarding influenza immunization for high risk children: follow-up on two reminder methods.

BACKGROUND: The aim of this study was to compare influenza immunization rates in children who were defined as high risk for complications following a letter or a phone reminder, and to survey parental opinions about influenza. METHODS: The 198 families of 930 children were targeted. After the season for immunization, a phone survey was conducted. RESULTS: A letter was sent to the families of 444 children. A telephone reminder was successful with the families of 288 children. The rates of influenza immunization were 15.3% and 13.5%, respectively. In the 86 families that were interviewed, 46.7% of the children in the families who got a reminder letter were immunized compared to 32.1% in those who got a phone reminder (P=0.184). Better knowledge, older parents, and larger families were associated with higher immunization rates. Major reasons for non-immunization were: potential side effects, lack of knowledge, and opposition to influenza vaccine. CONCLUSIONS: A reminder letter or a phone call did not lead to high rates of influenza vaccination in children, nor was there significant difference between the two reminder methods. Parental knowledge, attitude, and barriers for vaccination should be addressed when a reminder method is chosen.

Diurnal and seasonal variation of cough episodes in healthy young adults.

SETTING: We developed an algorithm to assess recorded cough episodes and differentiate them from similar, non-cough sounds. OBJECTIVE: To measure cough episodes in healthy young adults, cigarette smokers and non-smokers over a 24-hour recording period, during the course of normal activity. DESIGN: The study subjects were students, aged 20-40 years old. 24-hour sound recordings were conducted by a portable recorder. Analysis used an algorithm that was developed and tested in the study. RESULTS: Seventy students were recruited. Recordings included 2628 cough episodes in 1704 h of recording. The cough detection algorithm successfully detected 88.5% of recorded cough episodes and 95.6% of non-cough sounds. There was a clear tendency for more coughs among smokers. Autumn was the season with the highest mean cough episodes per day (58.65), while summer had the lowest (14.19). There was a strong correlation between self-reported cough episodes and recorded coughs. Cough episodes were significantly more frequent between noon and midnight (p < 0.0001). CONCLUSION: There is a very large range in daily coughs among healthy young adults. During sleeping hours there are less cough episodes. In autumn and spring there are more cough episodes compared to summer and winter, probably secondary to environmental factors. In smokers, the coughing rate is relatively high. If the cough detection device will be able to discriminate between cough variants (i.e., healthy versus patient), and stringent validation will confirm sensitivity and specificity, valuable data from this device may ease the decision regarding medications, or any other changes in order to improve outcome.

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.

Jewish holidays and their associated medical risks.

Religiosity is inherent in human cultures. Being different in many aspects, all have rules regarding appropriate behavior and rituals. Celebrations of social events and of holidays prevail in all major religions. These include code of dress, prayers, special food and activities which may have negative health implications. The Jewish religion is 'blessed' with an abundance of holidays each with its unique health implications. In this paper we provide an outline of the character of these festivals and possible medical repercussions on those celebrating them. Observant members of the Jewish religion and teams treating this population should be knowledgeable of potentially associated risks. Pre-holiday periods should be specifically targeted for educational and preventive activity in order diminish injury or morbidity.

Reducing health disparities: the social role of medical schools.

INTRODUCTION: Medical education based on the principles of social medicine can contribute toward reducing health disparities through the "creation" of doctors who are more involved in community programs. PURPOSE: This study compared the social medicine orientation of graduates from various medical schools in Israel. METHODS: The authors conducted an online cross-sectional survey in May 2011 among physicians who are graduates of Israeli medical schools. RESULTS: The study included 1050 physicians practicing medicine in Israel: 36% who are graduates from the Hebrew University, 26% from Tel Aviv University, 22% from the Technion and 16% from Ben-Gurion University. A greater percentage of physicians who studied either at the Technion or Ben-Gurion are working or have worked in the periphery (∼50% vs. ∼30% at the Hebrew and Tel Aviv Universities). Among Ben-Gurion graduates, 47% are active in social medicine programs vs. 34-38% from other schools. Among physicians active in social medicine programs, 32% of Ben-Gurion alumni estimated that their medical education greatly influenced their social medicine involvement vs. 8-15% from other schools. Hebrew University alumni described their studies as more research-oriented. In contrast, Ben-Gurion graduates described their studies as more social medicine-oriented and they exhibited more positive attitudes about the role of physicians in reducing health disparities. DISCUSSION: Social medicine-oriented medical education induces a socialization process reinforcing human values regarding doctor-patient relationships and produces positive attitudes among future doctors about social involvement. Findings emphasize the need to develop educational programs with this orientation and to strengthen medical schools in the periphery.

[The social role of the faculties of medicine: physicians' perception of the dominant orientation of their medical studies and social involvement].

BACKGROUND: Medical education, based on the principles of social medicine, has the ability to contribute to reducing health disparities through the "creation" of doctors who are more involved in community programs. AIMS: To compare the social and community orientation of graduates from the various medical schools. METHODS: An online cross-sectional survey among 12,000 physicians who are graduates of Israeli medical schools was conducted in May 2011. RESULTS: The study encompassed 1,050 physicians, Israeli medical school graduates living in Israel and practicing medicine: 36% were Hebrew University graduates, 26% were Tel Aviv University graduates, 22% were Technion graduates and 16% were Ben-Gurion University (BGU) graduates. Higher rates of physicians who studied at the Technion and BGU are working or have worked in the periphery (approximately 50% vs. approximately 30% average of Hebrew and Tel-Aviv University schools). Among BGU graduates, 47% are active in community programs vs. 34-38% in other schools. Among physicians active in community programs, 32% of BGU alumni estimated that their medical education greatly influenced their community involvement vs. 8-15% in other schools. Hebrew University alumni graded their studies as having a higher research orientation. In contrast, BGU graduates graded their studies as having a higher social orientation, and had more positive attitudes on the role of the physician in reducing health disparities. DISCUSSION: Medical education with a social orientation will induce a socialization process that reinforces human values regarding the doctor-patient relationship and produce positive attitudes among future doctors regarding their social involvement. The findings emphasize the need to develop educational programs with a social orientation and to strengthen medical schools in the periphery.

Enhancement of pediatric ophthalmologic diagnosis with a handheld polarized dermatoscope.

OBJECTIVE: In pediatric primary care, an adjunct for ophthalmology diagnosis and monitoring of treatment could be of great advantage. The portable polarized dermatoscope can readily fit the purpose as an alternative to the classic slit lamp device. METHODS: We describe and demonstrate our clinical experience using the dermatoscope for diverse ocular conditions. MAIN MESSAGE: Beyond its effective primary role as an examination tool for detecting dermatopathology, the dermatoscope proves its worth in a variety of separate ophthalmologic clinical states where intricate details need recognition. From corneal or subtarsal foreign body identification, to tear gutter assessment, this instrument can facilitate our work whenever magnification and illumination is beneficial. CONCLUSION: The technique described raises the option of using a substitute for usually lacking, cumbersome equipment for many therapeutic situations, rural clinics and home visits, easily available for the busy pediatrician, demanding little training, and at a reasonable cost.

Acute pharyngitis: low adherence to guidelines highlights need for greater flexibility in managing paediatric cases.

AIM: To describe how physicians manage acute pharyngitis with respect to the clinical guidelines. METHODS: The computerized medical records of 105 961 children in one district of a large health maintenance organization were analysed, to identify children aged 0-18 years with a diagnosis of pharyngitis and paying their first visit for pharyngitis. Main outcome variables were whether a throat culture was performed and the time between their medical consultation and purchasing any antibiotics, if at all. RESULTS: A total of 28 511 episodes of pharyngitis in 19 865 children aged 0-18, recorded by 125 physicians, were analysed (average of 1.4 episodes per child). Throat cultures were performed in 14 847 episodes (52%), with tests more common among paediatricians and younger physicians. Antibiotics were purchased in 24.8% of these cases, without knowing the result, and were more commonly associated with male physicians, family practitioners, children living in rural areas and drugs bought before the weekend. CONCLUSION: About 50% of the physicians did not adhere to the guidelines. Factors influencing adherence included physician training, years in practice and patients' nonmedical characteristics. It is suggested that the existing clinical guidelines should address additional modifiers that will make the more applicable in practice.

Normal hemoglobin at the age of 1 year does not protect infants from developing iron deficiency anemia in the second year of life.

BACKGROUND: Iron deficiency anemia (IDA) is the most common hematologic disorder worldwide. Measures to prevent IDA in infants have been successful with questionable sustainability. AIM: To evaluate the incidence of developing IDA in the second year of life, in infants who were nonanemic at the age of 1 year on routine blood test. METHODS: Blood samples were obtained from 193, 24-month-old toddlers, from 2 large clinics of both main sectors in Southern Israel, comparable for lower economic status. IDA was defined as hemoglobin < 11 gr% and microcytosis as mean corpuscular volume < 70 fL. RESULTS: IDA was detected in 8 of 118 Bedouins (5 males) and in 10 of 75 Jewish (6 males) infants (P < 0.01). The probability of a nonanemic child to develop IDA in the second year of life for the whole study population was 9.3% (18 of 193 infants) and significantly higher in the Jewish population (13.3.0% vs. 6.8%, P < 0.01). CONCLUSIONS: Given the difficulty of toddlers to maintain a non-IDA status, and the very low probability of iron overload, our results clearly support the need to continue iron supplementation into the second year.