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.

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.

[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.

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.

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.

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.

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.

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.

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.

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.

Voluntary dehydration among elementary school children residing in a hot arid environment

BACKGROUND

Voluntary dehydration is a condition where humans do not drink appropriately in the presence of an adequate fluid supply. This may adversely affect their physical and intellectual performance. The present study aimed to describe the prevalence of voluntary dehydration among elementary school children of different ethnicities and countries of birth.

METHODS

Four hundred and twenty-nine elementary school children, aged 8-10 years, from four subpopulations (Israeli-born Jewish and Bedouin-Arab children, and immigrant children who recently arrived to Israel from Eastern Europe and from Ethiopia) were studied. The level of dehydration was determined by noontime urine osmolality, from samples taken over 1 week in mid-summer. Urine osmolality <500 mOsmol kg(-1) H(2)O was considered to be an appropriate level of hydration.

RESULTS

Mean urine osmolality was 862 +/- 211 mOsmol kg(-1) H(2)O. Osmolality above 800 mOsmol kg(-1) H(2)O was detected in 67.5% of the urine samples; among these, 25% were above 1000 mOsmol kg(-1) H(2)O. The most dehydrated group was that of Israeli-born Jewish children, whereas the Bedouin-Arab children were the least dehydrated.

CONCLUSIONS

A high proportion of children who reside in a hot and arid environment were found to be in a state of moderate to severe dehydration. Bedouin ethnicity was associated with better hydration, whereas Israeli-born Jews were most severely dehydrated. Educational intervention programmes promoting water intake should start in early childhood and continue throughout life.

Who accompanies a child to the office of the physician?

The arrival of a minor, unaccompanied by a parent, for a clinic visit, is challenging to the physician with legal, ethical, and practical implications. This prospective study, conducted in three community pediatric clinics, examined the relationship of accompanying persons to the minors visiting the clinics. About 90% of the 1,104 visits were with an accompanying parent, mostly a mother. Over 9% of minors, especially adolescents, arrived at the clinic unaccompanied by a parent. A regression analysis demonstrated that for each increase of one month in age there was a 2% increased chance for a visit without a parent (p < .0001). Adolescents were more likely to be among the 6% of minors, who visited the clinic alone, with a rate 0.066 per 1,000 visits in the more affluent community, compared to 0.019 and 0.016 in the middle and low income communities (p < .001). Physicians as well as parents should be made aware of the regulations regarding accompaniment of minors on a visit to the clinic. Policies regarding unaccompanied visits should take into account the risk posed by the absence of a parent versus the right of adolescents for independence and privacy.

Parental attitude toward unaccompanied clinic visits of adolescents

To describe parental attitudes regarding the age and the type of medical problems that are appropriate for adolescent unaccompanied visits to the clinic at an age younger than 18 years.

METHODS

A structured interview was conducted with parents who visited two community clinics with their children. The questionnaire included: 1) At what age would you allow your child to visit the clinic alone? 2) What medical conditions are acceptable for unaccompanied visit at the age you stated (if lower than 18 years)? and 3) What medical conditions are not acceptable for unaccompanied visit at the age you stated (if lower than 18 years)?

RESULTS

Two hundred and fifty three parents were interviewed. There was an agreement between parents from the two clinics regarding the mean age appropriate for an unaccompanied visit (mean 14.1 +/- 2.56 years for clinic A and 13.8 +/- 2.66 years for clinic B). Medical conditions most acceptable for unaccompanied visits were common cold (clinic A = 77.4%, clinic B = 70.5%), sore throat (A = 64.5%, B = 84.3%) and fever (A = 34.7%, B = 19.4%). Medical conditions most unacceptable for unaccompanied visit were: injury (clinic A = 68.5%, clinic B = 53.5%), fever (A = 37.1%, B = 42.6%) and severe illness (A = 19.4%, B=23.3%).

CONCLUSIONS

most parents were willing to allow their adolescent children unaccompanied visits to the physician at an age below that stipulated by law. As unaccompanied visits are widely practiced and accepted by the public, it might be necessary to amend the law.

Referral criteria from community clinics to pediatric emergency departments

Referral of patients to a pediatric emergency department (PED) should be medically justified and the need for referral well communicated. The objectives of this paper were (1) to create a list of criteria for referral from the community to the PED, (2) to describe how community physicians categorize their need for referral, and (3) to determine agreement between the physician's referral letter and the selected criteria. We present a descriptive study of referrals to the PED of Soroka University Medical Center, Beer-Sheva, Israel, during February to April 2003. A list of 22 criteria for referral was created, using the Delphi method for reaching consensus. One or more criteria could be selected from this list for each referral, by the referring community physicians and, independently, based on the physicians' referral letters, by two consultants, and compared. There were 140 referrals included in the study. A total of 262 criteria for referral were selected by the referring community physicians. The criteria most frequently selected were: “Need for same-day consultation/laboratory/imaging result not available in the community” (32.1%), “Suspected life- or organ-threatening infection” (16.4%), and “Need for hospitalization” (15.7%). Rates of agreement regarding criteria for referral between the referring physicians and the two consultants, and a senior community pediatrician and a senior PED pediatrician, were 57.9 and 48.6%, respectively. We conclude that the standard referral letter does not convey in full the level of need for referral to the PED. A list of criteria for referral could augment efficient utilization of emergency department services and improve communication between community physicians and the PED.

Indices of iron deficiency and anaemia in Bedouin and Jewish toddlers in southern Israel

AIMS

To estimate the prevalence of iron deficiency and iron deficiency anaemia using haematological indices.

METHODS

Prospective interventional study. Healthy toddlers from Bedouin and Jewish towns in southern Israel. Capillary blood was sampled to assess iron status and nutritional history recorded. Parents were given specific nutritional instructions. Anaemia was defined as haemoglobin level < or = 11 gr/dL. Iron deficiency without anaemia was defined as mean corpuscular volume (MCV) < 70 fL and/or red blood cell width (RDW) > or = 16, with haemoglobin level > 11 gr/dL. Toddlers with iron deficiency were treated with 5 mg/kg/day of elemental iron. Follow-up iron and nutritional status was performed 1 and 2 months after enrolment.

RESULTS

At the time of enrolment 42% of the 107 Jewish and 93% of the 43 Bedouin toddlers were iron deficient (p < 0.001). Significantly higher proportions of Bedouin toddlers were breastfed, drank tea, did not eat meat, did not take supplementary iron in their first year of life and were previously diagnosed with anaemia. Rate of follow-up was 55% among Bedouins and 33% among Jews. The mean haemoglobin rise over two months was 0.91 gr/dL (95% CI: 0.63-1.18 gr/dL; p < 0.001) in Bedouins and 0.58 gr/dL (95% CI: 0.14-1.02 gr/dL; p = 0.014) in Jews.

CONCLUSIONS

Higher rates of anaemia and iron deficiency, as well as most of the risk factors, found among the Bedouin toddlers, call for the design and implementation of innovative, culturally appropriate interventions in the Bedouin population.

Risk factors for suicidal behavior in adolescents

Adolescent suicide is today a public health problem among the leading cause of mortality among adolescents and young adults. There seems to be many reasons for this increase (which has different trends in different populations), but associations have been found with increased substance abuse, television and video violence, socio-economic status and easy access to firearms. Gender differences have also been observed with crime, suicide and substance abuse higher among males, while eating disorder, depression and suicidal behavior more prevalent among females. This paper will review prevalence and incidence of adolescent suicidal behavior, socio-demographic and psychological risk factors, associated cognitive factors and socio-economic factors. Risk factors include previous suicide attempts, a history of others in the family who have been suicidal, mental illness, alcohol and drug use, and other self-destructive behaviors as well as consideration being given to hopelessness, hostility, negative self-concept and isolation. At the individual difference level, factors such as trait depression, anger and hostility, perfectionism and social sensitivity would seem critical variables, as would age, gender and intellectual functioning. Sociological and family-related factors may also be implicated including dysfunctional family organizations, a history of physical or psychological abuse (sexual abuse) and limited extent of social support networks. A frequently reported precipitating event of suicidal behavior is family adversity including rejection, separation and interpersonal conflict. At a socio-economic level it would seem essential to provide comprehensive document about the social and economic conditions from which the adolescent comes.

Cross-cultural medicine in the Middle East at the start of the 21st century: where East and West meet

The “global village” has resulted in the need to tackle cross-cultural issues in the medical school curriculum. The southern region of Israel (the Negev) provides a unique opportunity to study the interaction between medicine and culture. The Negev population is a multicultural society, with Bedouin Arabs comprising almost a fifth of its population. This imposes tremendous challenges to the medical establishment in the region and serves as a “cross-cultural laboratory” for educating medical students in global health issues. Both the traditional Israeli medical school track, as well as the newly established Medical School for International Medicine, incorporate studies of cross-cultural issues in various forms and to different degrees. Studies suggest that the exposure of students to international medical experiences increases their cross-cultural sensitivity and knowledge. We feel that in a region characterized by such ethnic diversity, all medical schools should adopt cross-cultural studies as an integral part of their curriculum.

Hubble bubble equals trouble: the hazards of water pipe smoking

A Narghile, one of the names for a water pipe, is an instrument for tobacco smoking that has became a trend among the youth in Israel. The mistaken opinion that smoking a Narghile is not as dangerous as smoking cigarettes makes the youngsters and their parents take it lightly and contributes to the expansion of its use. The objective of this paper was to review the literature on the health risks of Narghile smoking. A literature search of Medline (PubMed) and the Internet on the health hazards of Narghile smoking was conducted. The health hazards that the Narghile smoker is exposed to include interference with oxidation, damage to genetic compounds, increased risk of developing malignancies, infectious diseases, damage to the fetus and newborn, and exposure to commonly abused chemicals. It is concluded that increased awareness of the expanded use of the Narghile is imperative and education programs about the prevention of cigarette smoking and substance abuse should also include Narghile smoking.

Parental knowledge on car safety for children: an Israeli survey

The objective of this study was to assess the level of parental car safety knowledge and actual behavior regarding their children under the age of 15 years. This study forms part of the National Center for Child Safety and Health in Israel (Beterem) program to examine awareness on child safety. Seven hundred and five Jewish families with at least one child at home younger than 15 years (a total of 1,345 children) were used as a randomized sample of the Jewish population. A telephone survey was conducted by professional interviewers using a questionnaire developed by injury prevention specialists consisting of seven knowledge questions and a diagram that described the usual seating positions and restraining method of the family members in the family car. Concerning knowledge about injury prevention, the rate of incorrect answers was high,64% in regard to the proper car seats for age and 84% in regard to the age for booster seats. Sixty five per cent of parents did not know what a booster seat was and 54% did not know that the proper place for children was in the back seat. The average of incorrect answers was 4.86 out of 7 (SD=1.45) correlated with low socioeconomic status. Concerning care safety behavior 60% per cent of babies and 38% of toddlers were not restrained properly. This study should alert planners and policy makers to the need of implementation of educational prevention programs for the Israeli public of parents concerning car safety for children in order to reduce childhood injury.

Respiratory distress secondary to esophageal foreign body: a case report

The ingestion or aspiration of a foreign body is a common, but preventable occurrence in childhood. Primary healthcare personnel should alert parents to the risk of swallowing a foreign object, the signs and the need for immediate medical attention. It should be emphasized that protecting children from access to objects that can be swallowed or aspirated is the best preventive measure. A case of an eight year old child, who had swallowed a marble ball is presented and the symptoms and intervention discussed. Medical staff should be aware of the symptomatic variation in ingested foreign body presentation and the importance of rapid diagnosis and management.

The effect of voluntary dehydration on cognitive functions of elementary school children

AIMS

(1) To describe the occurrence of voluntary dehydration in two classes of elementary school students as expressed by their morning and noon-time urine osmolality; and (2) to determine the relationship between the children's scores on cognitive tests and their state of hydration.

METHODS

Group comparison among fifty-eight sixth-grade students (age range 10.1-12.4 y old) during mid-June at two schools in a desert town. Morning and noon-time urine samples were collected in school, and five cognitive tests were scored in the morning and at noon-time.

MAIN OUTCOME MEASURES

(1) morning and noon-time urine osmolality; (2) scores of five cognitive tests (hidden figures, auditory number span, making groups, verbal analogies, and number addition) that were applied in the morning and at noon-time.

RESULTS

Thirty-two students were dehydrated (urine osmolality above 800 mosm/kg H(2)O) in the morning. An individual's noon-time urine osmolality was highly related to morning osmolality (r=0.67, p=0.000). The morning cognitive scores were similar in the hydrated and dehydrated students (p=0.443). The adjusted mean scores of the noon-time tests, with the morning test scores as covariates, demonstrated an overall positive trend in four of the five tests in favor of the hydrated group (p=0.025). The effect was mainly due to the auditory number span test (p=0.024).

CONCLUSION

Voluntary dehydration is a common phenomenon in school-aged children that adversely affects cognitive functions.

[Should a minor, unattended by a parent, be given medical services? Use of an algorithm to critique the Israel Ministry of Health regulations]

BACKGROUND

Parents are the natural custodians of their children, thus minors need parental approval to receive medical services. In February 2004, the Israel Ministry of Health issued a set of regulations titled "Visits of unaccompanied minors to primary care clinics", aimed at assisting primary care clinicians in their decision-making process on this sensitive issue.

AIMS

(1) To convert the above mentioned regulations into an algorithmic format in order to facilitate their use by community clinicians, and (2) To review and critique the regulations, using the process of algorithm conversion.

METHODS

The regulations were studied thoroughly. Three rounds of Delphi process for reaching consensus were used to create an algorithm, based on these regulations. The algorithm building process was used to critique the regulations.

RESULTS

The Israel Ministry of Health regulations, "Visits of unaccompanied minors to primary care clinics", were found to be long and complicated. The process of building the algorithm revealed several difficulties certain concepts were not well defined, many exceptional situations were found and a large portion of the regulations was dedicated to reporting and record keeping. Converting the regulations into an algorithmic format simplified them and assisted in their

CONCLUSIONS

Converting complex regulations into an algorithmic format can facilitate their daily use by community clinicians. Parts of the regulations for "Visits of unaccompanied minors to primary care clinics" are incompatible with present clinic routine and, therefore, difficult to implement.

Child health care centres: an academic model for comprehensive child health care in the community

The challenge of the discipline of paediatrics in the 21st century is to promote health and development of children in a way that will enable them to maximize their biological and social potential. The community child health centre (CHC) in Israel is a model of community health care service built to provide comprehensive health care to children and adolescents, as well as an academic setting for under- and postgraduate paediatric training. Today there are 34 CHCs in Israel, serving a population of 220 000 children from birth to 18 years of age. The CHC combines the advantages of group practice with those of an academic medical centre and enables flexibility and mutual learning. Further expansion and development are required to realize the CHC's mission of a true comprehensive academic centre for paediatric community health.

Development and validation of a new measure of student attitudes and knowledge of international health and medicine

There is increasing awareness of the importance of international health and medicine (IHM) but there is a paucity of data regarding medical students' attitudes towards and knowledge of the subject. To the best of our knowledge there is currently no validated measure to assess this. The aim of the present study was to develop a validated measure of medical students' attitudes and knowledge of IHM and examine its correlates. A panel experienced in IHM formulated attitude and general knowledge items and clinical cases based on personal experience, literature review and texts. The survey was piloted and then administered to 82 students of the Ben Gurion University-Columbia University MD program in IHM, and 59 students from programs without specific IHM focus. Cronbach's a was 0.87. Test-retest reliability of attitudes was r=0.87. Correlation of openness to experience with attitudes was r=0.376, showing construct validity. Third-year IHM students scored higher than incoming students on IHM knowledge and clinical cases, demonstrating sensitivity. General IHM knowledge was positively correlated to clinical IHM knowledge r=0.36, but not attitude or openness to experience. Those with previous IHM work experience showed greater openness and positive attitude. Women showed more positive attitudes towards IHM than men. Attitude was negatively correlated with number of languages spoken r=-0.198. The survey may be a reliable and valid tool to assess and compare medical students' knowledge and attitude toward international health. This survey can be used to evaluate curricular innovations in the field.

Adolescents, accidents and the need to extend our scope of research

Accidents in adolescence result in mortality and disability that in many cases could have been prevented. The issue is a multi-factorial complex phenomenon, where new research ideas are needed to improve outcome. This short communication presents several research ideas that could provide new relevant answers.

[Family health centers in Israel: to change or not to be]

As reported in this issue, the Ministry of Health Family Health Centers (FHC) in Israel is not fulfilling some of the requirements of the Ministry of Health. For example, hemoglobin levels are not checked in all of the babies and at least 31% of the babies do not receive supplemental iron. Universal neonatal screening for hearing loss by objective methods is not conducted nor recommended by the Ministry of Health, as advised by pediatric professional organizations, while screening for hearing loss is conducted in the second half of the first year by a method which is not currently recommended. FHC physicians conduct initial screening for suspected developmental dysplasia for only some of the children, while too many children go directly to the orthopedic specialist. Previous studies have shown that only 20% of Jewish women residing in larger townships in Israel use the FHC for prenatal care. Based on all the above the government policy makers are facing hard decisions regarding FHC services. One option is to transfer all services to the health maintenance organizations. A second option is to maintain the FHC with the following modifications: 1) revise and update the health management guidelines to meet universal recommendations; 2) improve compliance to guidelines; 3) improve outreach and acceptance by the public of the services of the FHC.

Evaluation of student attitudes and knowledge in a new program in international health and medicine

Ben-Gurion University (BGU) in collaboration with Columbia University inaugurated a medical school in 1998, with the expressed purpose of training physicians in International Health and Medicine (IHM). The Beer-Sheva Survey of Attitudes and Knowledge in International Health and Medicine was given to the first graduating class and three control groups. The graduates of the new program retained their positive attitudes toward IHM and increased their knowledge of the subject. Further studies are necessary to document the effect of the program on the clinical practice of its graduates.

[Primary care approach to children with special needs]

Children with special needs have medical, educational, social and emotional needs which are significantly greater than the average needs of their healthy peers. They and their families have to struggle with the physical, economical and emotional burden imposed on them by their special needs. The role of primary physicians is to lead a team that is capable of diagnosing, treating and coordinating treatment and support for the child and the family. Case management and anticipatory guidance are the cornerstone of the art of dealing with children who have special needs. Primary community physicians are expected to conduct a survey in order to identify the children with special needs in the community and to prepare an intervention plan for each of them. Early detection and proper management of the problems are expected to help these children to maximize their potential and integration in society.

Skin reaction following immunization with smallpox vaccine: a personal perspective

Concerns about the possibility of bioterrorism or unconventional weaponry using the variola virus have emerged following the events of September 11, 2001. Immunization of emergency personnel in Israel against smallpox started in September 2002. This case report describes the skin reaction following immunization with vaccinia virus. Physicians should be aware of the variations at the site of the inoculation.

Introduction of computerized medical records. A survey of primary physicians

The purpose of the study was to survey primary physicians about the possible impact of computerized medical records on clinical practice.

METHODS AND DESIGN

236 primary care physicians from the Negev health district in Israel, attending a course prior to installation of computerized record keeping, were given two open-ended questions together with a twenty-four statement attitude questionnaire using a five point Likert scale.

RESULTS

The beliefs of physicians highlighted the potential that computerized charts can help with office work, prevent loss of information, and facilitate communication between medical staff. On the other hand, the survey indicated that physicians felt its application was not universal and were uncomfortable with the fact that its use is mandatory. There were major concerns relating to how the medical record was displayed, anticipated increase in workload, and presumed extra time needed for data entry.

CONCLUSIONS

Most of the physicians surveyed were positive regarding the help that computerized medical records could provide. They were, nevertheless, concerned with the burden of change and adaptation of new technology and software design to clinical practice and its affect on communication.

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.