Several themes and sub-categories were identified in the interviews.
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(a)
Involvement of community pediatricians in CD
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(a-1)
The current involvement of pediatricians
There was broad agreement among the interviewees that there was little involvement of community pediatricians in the area of CD and that—by and large—pediatricians did not constitute a significant or contributing factor in the detection of children with developmental delays or the identification and treatment of the problem. Moreover, the directors added, many pediatricians are not at all convinced that involvement in CD was part of their proper purview, and they are quick to transfer patients to another source of treatment without performing the basic activities expected of them by the interviewees.
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(a-2)
The desirable involvement of pediatricians
The interviewees would like to see community pediatricians more involved in the treatment of children with CD difficulties, notably in the following ways:
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1.
Pediatricians should conduct the primary medical evaluation and refer children with problems to relevant preliminary tests—such practice would save precious time upon the child’s arrival at the CD institute and, in some cases, rule out problems that are unrelated to developmental delays (e.g., celiac disease or anemia). As one interviewee put it:
For example, in cases of speech delay, pediatricians should send the child for a hearing test: The pediatrician would discuss the results with the parents and in the case of impairment, the child would be referred to the proper resource for treatment or for surgery (for a cochlear implant) obviating the long wait for an appointment at a CD institute. The interviewees noted that pediatricians generally serve as an important figure of authority for parents, and parents on the whole are responsive to a pediatrician’s recommendations regarding necessary tests or treatment.
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2.
Community pediatrics as a resource for concerned parents and the provision of guidance. In the case of mild BD problems when there is no need for a CD professional, a knowledgeable pediatrician can provide the warranted guidance rather than refer a child to the institute. One example cited by many of the interviewees is congenital muscular torticollis as sometimes exhibited by infants, which can be remedied with the help of simple exercises.
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3.
Direct referrals to therapists in mild cases, for instance, a Speech-Language Pathologist (SLP)—As evident from the interviews, most directors do not expect pediatricians to take it upon themselves to refer patients directly to therapists. However, a few did say that they would like pediatricians to be armed with that option (e.g., to physio- or SLP) in mild, defined cases such as a brief delay in the onset of walking or unclear pronunciation.
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4.
Exercising discretion before referring a child to a CD institute—The interviewees would like pediatricians to refrain from automatic referrals at the request of parents or the recommendation of a preschool teacher or nurse at a Maternal Child Clinic. The pediatricians should form their own impression of the child and exercise their discretion. If need be, they should explain to the parents that there is no cause for referral to a CD institute.
On this question, there was also a dissenting opinion. A few interviewees contended that since pediatricians lack sufficient knowledge of CD, they could potentially cause harm and, preferably, should not perform screenings at all.
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5.
Transfer of relevant information to the CD institutes—Written referrals constitute a work tool for institute physicians. They require detailed referrals to help staff arrive at a diagnosis. The valuable information includes: The child’s state of health, prior illnesses, prior hospitalizations if any, illnesses in the family, and CD-related aspects such as growth curve, head circumference, and prenatal (pregnancy) history. Information on the family and its background is also required. In many cases, community pediatricians have known a family for some time and are cognizant of its circumstances, residential milieu, and child-rearing practices
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(b)
Involvement of other parties in the identification of children with developmental delays
As understood from the interviews, in most cases pediatricians are not the first party to detect developmental delays in their patients. The active parties in this respect (apart from parents) are mainly nurses at Maternal-Child Clinics and preschool teachers. These parties refer the children to the pediatricians, who then refer the children to the CD institutes. The attitude of the interviewees to detection by preschool teachers was not uniform, some spoke of unnecessary referrals. Nonetheless, most commended the nurses and preschool teachers, asserting that they knew the children well, that they encountered them when healthy, and were able to assess their daily behavior and identify problematic cases. The Maternal-Child Clinics, for their part, devote structured time to the performance of developmental tests. Some interviewees, in fact, cited an opposite problem: Pediatrician disparagement of referrals by nurses and preschool teachers, which resulted in their missing signs that do require attention. However, as described below in the section on problems that aggravate the overload of CD institutes, some pediatricians believe that preschool teachers occasionally refer children who do not require treatment there, not due to mistaken detection but in order to relieve the burden on the preschool. In their opinion, the children will receive medical treatment in order to calm them down.
The interviewees voiced their sense that the system of CD institutes sometimes serves as a solution for other systems suffering from shortages and lack of workforce, causing the overload at the institutes. The education system was cited in this connection as it suffers from overcrowding and is understaffed. One interviewee described the process that brings children to the institutes who should not be there:
A preschool teacher desiring the assistance of a special education preschool teacher in order to obtain help and ease her work somewhat, gets hold of the parents and tells them, ‘Listen, [your child] must have occupational therapy, there is a serious problem.’ […] and [whereas] the parents pass on questionnaires to me that show the child to be perfectly normal […] and should I say … that I am not referring them for diagnosis, I receive calls from a stressed parent twice a week: ‘But the preschool teacher said, the preschool teacher said.’ So it is not only that we receive unnecessary referrals, but we also perform unnecessary diagnoses, knowingly (interviewee no. 13).
The situation is similar in pediatric mental health, which suffers from a serious shortage of professionals and for which the CD institutes constitute a relatively accessible alternative. In the opinion of the directors, some referrals to the institutes stem from lack of knowledge on the part of pediatricians; rather than to an institute neurologist, the children should have been referred a psychiatrist. That being said, it was evident from the interviews that in early childhood, the boundary between the two areas is not always clear.
The interviewees mentioned an additional approach of early detection and response to mild problems. They suggested that CD professionals be introduced into Maternal-Child Clinics to provide brief interventions and determine whether to refer a child to the institutes or to offer short-term treatment at the clinics.
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(iii)
Barriers to the involvement of community pediatricians in CD diagnosis and treatment
The interviewees cited several key barriers which they believe deter community pediatricians from greater involvement in CD diagnosis and treatment: Lack of time, lack of compensation, and insufficient clinical knowledge.
Lack of time—Of all the barriers cited, the interviewees perceived the lack of time as the most severe and they related to it from several aspects:
They believe that lack of time is a constant for community pediatricians. Appointments are extremely overbooked and, during visits, for which only a few minutes are allotted, pediatricians are unable to check whether a child’s development is normal. Moreover, they are aware that other patients are waiting outside their door, which, in the directors’ opinion, only adds to the pressure of the pediatricians’ work and rules out their devoting the time needed to check a child’s development.
Moreover, pediatricians have no assigned time for routine check-ups of healthy children in their care. One check-up program initiated by a health plan did not meet with success. According to the directors, Israeli culture dictates that parents bring their children to a pediatrician only when ill. Healthy children do not visit pediatricians on a routine basis; and during a pediatrician’s examination for a cold or pneumonia, for instance, there is no real time to check a child’s development. The directors expressed an interest in instituting a different type of visit to community pediatricians.
Compensation strategy for pediatricians—The lack of time relates also to the type of compensation pediatricians receive. Some community pediatricians (an estimated 40%) are self-employed and paid according to the number of visits made to them. Thus, if a visit takes too long, they see fewer children and their payment is smaller. The interviewees affirmed that CD examinations are lengthy and pediatricians should be compensated for them. A minority opinion contended that the mere fact of compensation would itself encourage community pediatricians to address the topic.
Lack of knowledge—Some interviewees mentioned the barrier of lack of CD knowledge on the part of community pediatricians. At the time of writing, the pediatric residency programs in Israel take place in hospitals, with no emphasis on community pediatrics. A block rotation in CD is not mandatory for pediatric residents either. Trainees wishing to acquire the necessary knowledge of CD must do so at their own initiative. The position of the interviewees was that pediatricians should receive at least minimal training in the topic and they require basic instruction at the level of primary clinics (e.g., training in Speech-Language Pathologies (SLP)). However, given the heavy workload of community pediatricians, the directors were not optimistic that such training would be easy to implement.
Additionally, not only the young generation of physicians lack sufficient knowledge of CD. The same is true of older pediatricians, as noted by one of the interviewees:
There is a problem in Israel at the level of skill and training for primary medicine. Therefore, I would address it throughout the physician’s careers […]: That is, for older physicians – via the health plan’s system of onsite training; for medical students – via the faculties and pediatrics residency where most of the work should be done. I would create a syllabus that definitely exposes them to these topics so that a generation of pediatricians rises for whom this language is not foreign (interviewee no. 18).
The result of this is that physicians encounter problems in the area of CD and do not have the tools to address them.
They sit at a clinic in a neighborhood where for a decade they see no […] child requiring intensive care [yet…] dozens and hundreds of children requiring CD [care] and not once in five years have they visited a CD institute. You can transcribe this in large writing with an exclamation mark and send it straight to the Scientific Council.
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(iv)
Possible ways to increase the involvement of community pediatricians
Several ways to increase the involvement of community pediatricians in the treatment of developmental and emotional problems were proposed in the interviews. The main suggestions were:
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(d-1)
Change of pediatric training. The reference here is to integrate CD into the pediatrics residency to expose pediatricians to the contents and familiarize them more closely with the area. Another suggestion was that pediatric specialists receive simple, basic training focusing on the milestones of development to enable them to conduct informed screening and to winnow out the children referred to the institutes without cause. Another suggestion was that special training be provided to physicians interested in the area and that, subsequently, they be allowed to devote some of their time to working with children suffering from mild problems and referred to them by other physicians. These physicians would not replace CD physicians; rather, they would constitute an interim step between pediatricians and the institutes, somewhat easing the latter’s overload.
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(d-2)
Use of online consultation by CD specialists for community pediatricians. This would help the latter provide a response to DB problems, obviating the need for some referrals to the institutes. One interviewee said that her health plan did indeed offer this resource and physicians did avail themselves of it.
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(d-3)
Incentives for community pediatricians to perform periodic health reviews with the help of validated tools. Physicians would complete a screening questionnaire for children at specific junctures and receive compensation for the time spent.