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Pediatric Neurology Referrals in Armenia: Lessons

We Can Learn

The pace of change in medicine—in the world—means that we cannot afford to live in silos. We need to reach beyond our borders, to teach, and to be taught, by people from other disciplines, with other politics, from other cultures. On that premise, and considering the prevalence of ethnic Armenians among his in-laws, one of us (Dr Bingham) arranged a 5-month sabbatical in Armenia. In addition to conducting collaborative teaching exercises and clinical work, the project, sponsored by the Fulbright Scholar Program of the US State De-partment, aimed to better understand working relationships between pediatric neurologists and pediatricians in the context of referral.

Having survived in the last 100 years a genocide, decades of totali-tarianism, a major earthquake, a border war, and a massive exodus of its population (10 million diasporan, 3 million native Armenians), Armenia represents one of the oldest, and perhaps most resilient, cultures on earth. Like several other post-Soviet countries, Armenia is a land-locked, developing country in central Asia. Its health care system, in transition from the former Soviet system, combines a fee-for-service system with a governmental insurance program1 for children under age 7 years, or for individuals who have disabilities, or belonging to other socially vulnerable groups. Despite fragmentation, the authority of the central Ministry of Health, and of hospital directors, reflects a health care bureaucracy that persists from the Soviet era.1,2 Pediatric clinicians thus cope with a hierarchical ad-ministrative system that has historically been disinclined to foster self-regulation.2

Semi-structured interviews with a convenience sample of Armenian clinicians (20 pediatricians, 6 pediatric neurologists) revealed strik-ingly similar referral scenarios between the United States and Armenia, and the continuing impact of the Soviet health care system, a“single payer”system that ended 25 years ago. In Armenia, as in the United States,3–5 a set of recurring complaints, often brought to clinical attention by parents perceived as disproportionately worried, prompt many referrals: angry, explosive behaviors; febrile seizure; benign macrocrania; fussy, sleepless infants; tics; mild head trauma; breath-holding spells; and headache. Pediatricians justified these referrals by using pragmatic and ethical rationales founded in be-neficence; considering the specialists’ authority and skills, referral could assuage parental fears and help avoid missing important AUTHORS:Peter M. Bingham, MD,aBiayna Sukhudyan,

MD,band Artsruni Hakobyan, MD, PhDc

a

Department of Neurology, University of Vermont, Burlington, Vermont;bYerevan State Medical University and“Arabkir” Medical Center; andc“Surb Grigor Lusavorich”Medical Center, Yerevan, Armenia

KEY WORDS

pediatrics organization and administration, referral and consultation, professional autonomy, education, pediatric neurology, health care systems, referral practice, specialty medicine

Dr Bingham conceptualized and designed the interview study that inspired the report and drafted the initial manuscript; Drs Sukhudyan and Hakobyan contributed to planning and design of the interview study that is the basis for the report, coordinated and facilitated data collection, and critically reviewed the manuscript; and all authors approved thefinal manuscript as submitted. All authors are practicing pediatric neurologists.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-0254

doi:10.1542/peds.2014-0254

Accepted for publication Apr 29, 2014

Address correspondence to Peter Bingham, MD, Department of Neurology, 1 South Prospect St, Burlington, VT 05489. E-mail: peter.bingham@uvm.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2014 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE:Dr Bingham serves as a paid consultant to the Health Resources and Services Administration, Division of Vaccine Injury Compensation, reviewing vaccine injury cases; and Drs Sukhudyan and Hakobyan have indicated they have nofinancial relationships relevant to this article to disclose.

FUNDING:Supported in part by a Fulbright Scholar Award (US State Department), which supports international cultural exchange among scholars, to Dr Bingham. Dr Bingham coauthored the Fulbright research proposal with Dr Sukhudyan.

POTENTIAL CONFLICT OF INTEREST:The authors have indicated they have no potential conflicts of interest to disclose.

PEDIATRICS Volume 134, Number 3, September 2014 e639

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diagnoses.4Although often happy to see healthy children who have simple con-cerns, pediatric neurologists expressed apprehensions regarding these refer-rals’impact on access to their services.

Generalists and specialists often

re-flected on distressing trends—some of them direct legacies of Soviet medicine—bearing on finances, geo-graphic dispersion, education, and professional autonomy.

FINANCES

As the Armenian health care system, like the Armenian economy and polit-ical system, continues to transition from Soviet communism, salaries for pediatric clinicians remain untenably low ($2000 to $10 000).1,2Poor compen-sation for time spent educating fami-lies may add motivation to refer. In other respects industrially advanced, the Soviet economy de-emphasized pharmaceutical industrialization; Arme-nia now depends on imports for over 95% of pharmaceuticals.1Even as they voice concern over non– evidence-based prescribing practices of some colleagues, pediatricians and sub-specialists also note that many fami-lies cannot afford medication.

GEOGRAPHIC DISPERSION

Soviet specialists were often sepa-rated among urban hospitals accord-ing to their discipline.1,2 As a result, neonatology consults, for example, re-quire travel by Yerevan’s pediatric neu-rologists to hospitals housing NICUs. Families’ lengthy travel time from out-lying regions highlights the conundrum of how to balance screening and re-ferral by pediatricians with optimal geographic dispersion of specialists.4,5

EDUCATION

Soviet-era teaching and traditions that emphasized laboratory testing spawned generations of clinicians who use

ra-diologic studies as screening tools, and also grandparents who expect radiologic testing for their grand-children. The excessive use of head ultrasound to screen populations con-stitutes one example of how Soviet-era teaching continues to influence re-ferral patterns, as well as families’ apprehensions and expectations. Chil-dren who have benign external hy-drocephalus are often inappropriately treated with acetazolamide when head ultrasound revealsfindings consistent with that condition.

Partly as a result of the Soviet“Semashko” model that emphasized specialty care,2 many general pediatricians lack train-ing in common neurologic or develop-mental signs or symptoms in infants and children. This educational gap ham-pers pediatricians’ability to respond to worried parents who may, in turn, de-mand specialty referral. As Armenian pediatric neurologists have taken steps to educate their generalist colleagues regarding common, simple concerns, pe-diatricians increasingly take on responsi-bility for these cases (eg, febrile seizures).

SELF-REGULATION

Specialists and general pediatricians at referral centers in Yerevan fre-quently accommodate families await-ing unscheduled visits—referred and self-referred—at their office door. The Ministry of Health has in the past mandated that families presenting after day-long drives with referral doc-umentation in hand must be seen on the same day. Clinicians who have been able to negotiate with their Directors (who own and administer the hospi-tals) have sometimes been able to in-duce reforms in these scheduling rules.

SOVIET INFLUENCES: POSITIVE LEGACIES

Thanks to the strong emphasis on specialty medicine in the Soviet era,

the ratio of pediatric neurologists to population served in Armenia is sim-ilar to that in the United States (total

∼25, population near 3 million). Per-haps because only a small percentage of the population actually uses the health care system,1 it is possible to see a pediatric neurologist in Yerevan within a week of referral. Armenian pediatricians differ from US pedia-tricians4 in voicing satisfaction with the availability of their colleagues in pediatric neurology.

The Soviet medical system had strengths in the arenas of rehabilitation medicine, as well as prevention and treatment of infectious disease,2 and the Ministry of Health has extended its rehabili-tation network with newer “Centers for Development and Rehabilitation Health” throughout the country. Im-munization rates exceed 90% in many villages in outlying regions around Armenia,1which means prevention of neurologic sequelae of brain infec-tions. The coherence and camaraderie between pediatrician and pediatric neurologist seems relatively strong in responding to cases of meningitis or encephalitis.

Just as in the United States,4,5,6 Ar-menian pediatric hospital centers and pediatricians are in the midst of a transition,1 with increasing pressures on primary care practitioners to as-sume new responsibilities so as to avoid specialty referral. Armenian pe-diatric clinicians continue to struggle for consensus regarding which pa-tients should be referred, and with what urgency. And the target is mov-ing; Armenian clinicians, similar to US pediatricians,3describe increasing complaints related to attention-deficit/ hyperactivity disorder and autism. Al-though Armenia’s sole medical school, Yerevan State Medical University, cur-rently lacks a Pediatrics Department, clinicians hope for the resuscitation of a vigorous, productive department

e640 BINGHAM et al

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like the one they remember from So-viet times.

Despite our disparate cultural, eco-nomic, and political history, the con-cerns and tensions associated with the referral process in Armenia reso-nate strongly with those of US pedia-tricians and pediatric neurologists. In both countries, specialists’ evaluation can benefit the families of children who have common, benign conditions by alleviating anxiety, but may interfere with specialists’capacity to see sicker patients; in both countries, stigma

asso-ciated with neurologic disease undoubt-edly colors the referral process7; in both countries, clinicians often lack local organizational structures that could facilitate their quest for greater autonomy, or transition to more effi -cient distribution of health care sys-tems. Cooperative international efforts will need to carefully examine how and whether US or European guidelines can be adapted to developing post-Soviet countries like Armenia.

We in the west can also learn from Armenians’ dedication and

resource-fulness as they provide health care on a shoestring budget. Our meetings showed how similar our educational needs, as well as those of the families and communities for whom we care, can be. Looking ahead, international collaborations among pediatricians and pediatric neurologists will do well to identify educational programs that assist general practitioners and fam-ilies to distinguish common, benign, symptom complexes from more seri-ous conditions.7

REFERENCES

1. Richardson E, Nazaretyan M, Makarova T, Aristakesyan M, Margaryants H, Nolte E. Armenia: health system review.Health Syst Transit. 2013;15(4):1–99

2. Tragakes E, Lessof S. In: Tragakes E, ed.Health Care Systems in Transition: Russian Federa-tion. Copenhagen, Denmark: European Observa-tory on Health Systems and Policies; 2003:5(3) 3. American Academy of Pediatrics. America’s children need access to pediatric sub-specialists [position paper]. Available at:

www.aap.org/en-us/about-the-aap/departments-and-divisions/depar tment-of-education/ Documents/Sec5203FactSheet.pdf. Accessed June 30, 2014

4. Bale JF Jr, Currey M, Firth S, Larson R; Executive Committee of the Child Neurology Society. The Child Neurology Workforce Study: pediatrician access and satisfaction.J Pediatr. 2009;154(4): 602–606, e1

5. Mayer ML. Are we there yet? Distance to care and relative supply among pediatric

medical subspecialties.Pediatrics. 2006;118 (6):2313–2321

6. Ferriero DM, Hauser SL. Supply does not satisfy demand in child neurology. Ann Neurol. 2010;67(5):A5–A6

7. Committee on Nervous System Disorders in Developing Countries, Institute of Medicine, Board on Global Health.Neurological, Psychiat-ric, and Developmental Disorders: Meeting the Challenge in the Developing World.Washington, DC: National Academies of Science Press; 2001

PEDIATRICS PERSPECTIVES

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DOI: 10.1542/peds.2014-0254 originally published online August 25, 2014;

2014;134;e639

Pediatrics

Peter M. Bingham, Biayna Sukhudyan and Artsruni Hakobyan

Pediatric Neurology Referrals in Armenia: Lessons We Can Learn

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DOI: 10.1542/peds.2014-0254 originally published online August 25, 2014;

2014;134;e639

Pediatrics

Peter M. Bingham, Biayna Sukhudyan and Artsruni Hakobyan

Pediatric Neurology Referrals in Armenia: Lessons We Can Learn

http://pediatrics.aappublications.org/content/134/3/e639

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