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Pediatrics discuss cpecialized assistance to children at Tel-Aviv conference

Infants, toddlers, children and teens are the most vulnerable population anywhere, and they deserve protection by their families, pediatricians and society. The American Academy of Pediatrics is an organization of 66,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to their health, safety and well-being in the US and around the globe.

The outgoing president of the academy, Prof. Fernando Stein, made a first visit to Israel late last month to attend the annual conference of the Israel Pediatric Emergency Medicine Society, chaired by Dr. Shai Ashkenazi, head of one of the pediatrics departments at Schneider Children’s Medical Center in Petah Tikva. The conference, at the Tel Aviv Fairgrounds, brought together more than 1,000 Israeli doctors and nurses who treat children to discuss a variety of subject from drugs for infections and seizures to the diagnosis of autism vaccinations and “burnout” among pediatricians. 

Born in Guatemala, Stein was the son of a Catholic mother and a Jewish father who was a photographer and died of a heart attack when Fernando was only 10 years old. His mother, left with five children aged one to 15, worked with photographers and kept the business going. Fernando studied medicine in Guatemala and moved to the US 41 years ago to do postgraduate studies at Baylor Hospital in Houston, where he settled down. He told The Jerusalem Post in an interview that had his father suffered from a heart condition today, modern medicine would have probably prevented his death at a young age.

Stein, a practicing pediatrician and critical care specialist at Texas Children’s Hospital, began his one-year term as AAP president on January 1 of this year, so he is due to finish his term in a few weeks. The term for academy presidents is short, he said, because the academy’s national headquarters is in Itasca, Illinois and its federal affairs office in Washington, DC. Thus his medical practice at the hospital and his teaching at Baylor were mostly suspended while serving in the post. Stein has delivered bedside care to children for the past 35 years in Houston and was there when the devastating hurricane hit the city a few months ago. He is a founding member of the AAP’s Section on Critical Care and a past member of the Council on Sections Management Committee and Committee on Membership. He is also one of the original members of the Task Force on Minorities and has been an advocate for children in impoverished environments at the global level.

A leader in the area of chronically ill, he has supervised some 1,300 medical residents learning pediatrics over the decades. His areas of research have included patient and family communications in clinical environments and mechanisms of death in children with severe neurological disabilities.

Although he has contact with Israeli pediatricians, it was his first visit to the country. “I have a dear friend, Dr. Hillel Hurwitz, who is a pediatrician in Ra’anana who works at the Herzliya Medical Center. We were neighbors in Houston, and our daughters were born on the same day in 1980. Hillel immigrated to Israel in 1997, but I suppose we were both busy with our careers, so we never met before in Israel.” Finally, when invited to speak at the Tel Aviv conference, he decided to make the trip.

Stein spoke at the conference about a hot topic among Israeli pediatricians: about one-third of pediatricians – both in hospitals and community health clinics – suffer from occupational burnout, according to a new survey of the Israel Pediatrics Association. Studies in the US have shown that burnout is especially high among family physicians and emergency medicine specialists.

The level of such long-term, unresolvable job stress is directly connected to the number of doctors who consider completely leaving the profession of medicine. A total of 238 Israeli pediatricians took part in the survey, which was a follow-up to a similar study from 2006. The aim of the new poll was to note trends and causes of burnout. Among the respondents, 19% work in administrative positions, 73% in the community and 6% in hospitals. More than 40% are independent pediatricians working for health funds, 40% are salaried physicians and 19% work both independently and as salaried doctors. A quarter of those who responded had academic status with medical schools.

Burnout is less common among specialists than it is among general practitioners, while those who teach in medical schools show more satisfaction in their work. Salaried pediatricians suffer more from burnout than independent doctors do. The younger the pediatrician and the longer the workday, the more tired and fed up they are, according to the poll. Having to do a lot of administrative “red tape” also increases burnout. Teaching medical students and doing research decreases the rate.

Since 2006, the difference in burnout rates between pediatricians who teach students, do research, attend medical conference and work on health promotion and those who do not increased significantly. There was more burnout in 2017 among pediatricians who had a lot of red tape to deal with than there was in 2006. The Israel Pediatrics Association reached the conclusion that their members should be allowed to attend more medical conferences and advanced medical education programs, teach students, carry out research and be involved in disease prevention and health promotion.

Stein noted that pediatricians in the US do not suffer more from burnout than specialists in a number of other fields. The highest stress is in neurology, anesthesiology, urology, family medicine and emergency medicine. “It attacks everybody, but fields with the lowest incidence of burnout are psychiatry, obstetrics/gynecology and ophthalmology. “The proven antidote to burnout is compassion. You give and, it is hoped, also get things in return. You need a life-long educational commitment to your field and continuing medical education throughout your career. Fortunately, I have never suffered from burnout,” Stein asserted.

Managed care, in which health maintenance organizations tell US doctors what to do – sometimes denying patients what their doctors want to do and prescribe – is partly responsible for doctor burnout, Stein suggested. “There are administrative barriers, as the HMOs are trying to save money. Doctors complain about depersonalization, a loss of control of one’s work environment and a lack of understanding and support by administrators for how medicine is practiced.”

Doctors who see outpatients have an average of only 12 to 20 minutes to see, diagnose, prescribe and treat each patient (the average is even lower in Israel). “But a good physician will somehow try to give a patient all the time they need. However, this is a bit of a trap, since if you spend half an hour with one patient, the next one will have to wait and have less time. This can lead to criticism from one’s administrators.” With infection rates declining in the developing and developed worlds, mortality in children has dropped by more than 60% over the last six decades, said Stein.

“Non-communicable diseases from heart diseases to stroke, obesity and diabetes worry us everywhere. Life expectancy has increased, but it is an illusion that were doing very well, because we are often prolonging years of unhealthy lives. From 1990 to 2013 – only 23 years – life expectancy of Americans increased by 17 years, but when you look at the functioning activities of daily life, they enjoyed only four or five more healthy years, with the rest suffering from some sickness or serious illnesses. Many of these begin in childhood. Baby Boomers are living shorter lives than their parents because of obesity and other chronic illnesses.”

The AAP maintains a strong pro-vaccination position. “Vaccinations against child diseases can prevent many deaths and even some types of cancer. They should be mandatory. We have supported legislative efforts in various states setting down the only valid exception to vaccination being a medical reason for refusal,” said Stein. “The community is at risk as number of unvaccinated children goes up. Immune-deficient children who cannot get a shot for medical reasons are put at risk.”

In the US, only California and Mississippi have passed laws that require vaccinations. The others leave the decision to parents. Fortunately, he continued, although the Internet is full of vaccine opponents, the rate of immunization in the US is not declining. People understand that the scientific evidence for the shots being beneficial is there and proven.” The academy also has a firm stand in favor of fluoridation of drinking water, which in Israel was halted by objections from then-health minister Yael German three years and has not yet been restored by her successor Ya’acov Litzman due to litigation and bureaucracy. “An Israeli dentist told me that she is seeing a large number cavities in children’s teeth that she didn’t see during fluoridation. Would opponents want to stop chlorination too? It would cause widespread dysentery.”

THE AAP took an official position on newborn male circumcision some five years ago. After a comprehensive review of the scientific evidence, it found that the health benefits of the practice outweigh the risks, but the benefits are not great enough to recommend universal newborn circumcision. Yet the final decision should still be left to parents to make in the context of their religious, ethical and cultural beliefs, the academy said. The organization also strongly advocates breastfeeding and providing facilities at work and other public places to make it easier for new mothers. The corporate environment is not friendly to nursing women on the job. The US lags behind many industrialized nations in providing facilities for breastfeeding and pumping,” he said.

Shockingly, although some workplaces in US provide maternity leave for women, “it is not a legal right, and many new mothers have to return quickly to their jobs. Again, corporate America is against it.” Stein urged that more be done in Israel to protect children from highly toxic tobacco smoke, in their homes, cars and public areas. Young Americans are very endangered by the opioid epidemic – legal and illegal drugs supplied on the Internet and by physicians who unnecessarily give prescriptions to patients who say they suffer from pain. Tens of thousands of people who overdose on the drugs have suddenly died, even dropping in the street.

Stein also worries about the US crisis of 150,000 unaccompanied children, many of whom came illegally. “We say that children do not immigrate alone. They flee from areas of violence, famine and abject poverty. There is gang activity and violence, famine and abject poverty in El Salvador, Honduras and Guatemala, concluded the native South American.

“Some parents send their children away to save their lives. Jews understand this from the Kindertransport in the Nazi era. We have to protect the children.”

Judy Siegel-Itzkovich