[THE NATIONAL FINAL INTERNAL MEDICINE EXAMINATION SCORE - IS IT PREDICTABLE?]

INTRODUCTION: There is no current medical licensing examination in Israel (2016). The only objective indicators which reflect students' medical knowledge and basic clinical reasoning skills are the national medical examination scores. The aim of the present study was to investigate the nature of the relationship between students' demography, gender and academic achievements during their pre-clinical studies and their final national internal medicine examination scores. METHODS: The study was based on data collected by the Technion information system. The study cohort consisted of medical students admitted to the Technion Faculty of Medicine over a decade from 2005-2014, via a standard admission procedure. Students accepted on the basis of former academic achievement were not part of this cohort. The cohort was divided into three, based on the level of success in the final national examination in internal medicine. CONCLUSIONS: Our main conclusions were: (1) the admission screening criteria (scores of matriculation and psychometric tests) are helpful markers for predicting success in the final examination in internal medicine; (2) students who performed the psychometric tests in the Arabic language have relatively lower-achieving grades in the final examination in internal medicine in comparison to students taking the same psychometric exam in the Hebrew language. Furthermore, (3) high achievements in core preclinical courses and especially in the "integrative course" in the first 2 trimesters of the fourth year of studies are relatively strong predictors for success in the final examination in internal medicine.

Student-centered tutoring as a model for patient-centeredness and empathy.

BACKGROUND: Curriculum planners and medical teachers attempt to enhance medical students' empathy and patient-centeredness. Despite educational efforts, there is stability in medical students' empathy and patient-centered medicine during the preclinical stage and a decline in both of them throughout the clinical years. Student-tutor relationship plays a key role in students' learning. This study tests the effect of learner-centered tutoring on students' empathy, patient-centeredness, and behavior. PARTICIPANTS AND METHODS: The cohort of 55 students was divided into groups of seven or eight. The experimental group's tutors underwent LC mentoring. Empathy was assessed with the Jefferson Scale of Physician Empathy for Students; PC attitude was assessed with the Patient-Provider Orientation Scale (PPOS). Behavior was assessed by simulations of doctor-patient encounters with 32 students at the end of the third year. Each student participated in three such simulations, during which we analyzed ten aspects of physician-patient communication via Roter interaction analysis system (RIAS)-coded audiotapes. RESULTS: A significant group difference was found for three RIAS categories: building a relationship and patient-centeredness, where the mean percentage of the experimental group was significantly higher than that of the control group, and gathering data, where the mean percentage of the experimental group was significantly lower than that of the control group. A significant correlation was found in the experimental group between empathy and positive talk and between PPOS and three of the RIAS categories: gathering data, psychosocial talk, and patient-centeredness. A significant negative correlation was found in the experimental group between PPOS and two of the RIAS categories: negative talk and doctor-centeredness. Two significant negative correlations were found in the control group: between empathy and patient-centeredness and PPOS and negative talk. CONCLUSION: The LC approach supports two of the RIAS categories, corresponding to clinical empathy and PC care and the link between certain behaviors and the PPOS.

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.

The clinical integrative puzzle for teaching and assessing clinical reasoning: preliminary feasibility, reliability, and validity evidence.

BACKGROUND: Expertise in clinical reasoning is essential for high-quality patient care. The Clinical Integrative Puzzle (CIP) is a novel assessment method for clinical reasoning. The purpose of our study was to further describe the CIP, providing feasibility, reliability, and validity evidence to support this tool for teaching and evaluating clinical reasoning. METHODS: We conducted a prospective, randomized crossover trial assessing the CIP in second-year medical students from a single institution. Feasibility was estimated through the time taken to complete a CIP during a CIP session and through comments from faculty developers. Reliability was addressed through calculating odd-even item reliability (split-half procedure) for grid questions within each CIP. Evidence for content, concurrent, and predictive validity was also measured. RESULTS: 36 students participated in the study. Data suggested successful randomization of participants and nonparticipants. The CIP was found to have high feasibility, acceptable reliability (0.43-0.73 with a mean of 0.60) with a short time for CIP completion. Spearman-Brown correction estimated a reliability of 0.75 with completing two grids (estimated time of 50 minutes) and 0.82 for three grids (estimated time of 75 minutes). Validity evidence was modest; the CIP is consistent with clinical reasoning literature and the CIP modestly correlated with small group performance (r = 0.3, p < 0.05). CONCLUSIONS: Assessing clinical reasoning in medical students is challenging. Our data provide good feasibility and reliability evidence for the use of CIPs; validity data was less robust.

Growth hormone (GH) receptors in prostate cancer: gene expression in human tissues and cell lines and characterization, GH signaling and androgen receptor regulation in LNCaP cells.

Various hormones and growth factors have been implicated in progression of prostate cancer, but their role and the underlying molecular mechanism(s) involved remain poorly understood. In this study, we investigated the role of human growth hormone (GH) and its receptor (GHR) in human prostate cancer. We first demonstrated mRNA expression of GHR and of its exon 9-truncated isoform (GHR(tr)) in benign prostate hyperplasia (BPH) and prostate adenocarcinoma patient tissues, as well as in LNCaP, PC3 and DU145 human prostate cancer cell lines. GHR mRNA levels were 80% higher and GHR(tr) only 25% higher, in the carcinoma tissues than in BPH. Both isoforms were also expressed in LNCaP and PC3 cell lines and somewhat less so in DU145 cells. The LNCaP cell GHR protein was further characterized, on the basis of its M(r) of 120kDa, its binding to two different GHR monoclonal antibodies, its high affinity and purely somatogenic binding to (125)I-hGH and its ability to secrete GH binding protein, all characteristic of a functional GHR. Furthermore, GH induced rapid, time- and dose-dependent signaling events in LNCaP cells, including phosphorylation of JAK2 tyrosine kinase, of GHR itself and of STAT5A (JAK2-STAT5A pathway), of p42/p44 MAPK and of Akt/PKB. No effect of GH (72h) could be shown on basal or androgen-induced LNCaP cell proliferation nor on PSA secretion. Interestingly, however, GH caused a rapid (2-12h) though transient striking increase in immunoreactive androgen receptor (AR) levels (< or =5-fold), followed by a slower (24-48h) reduction (< or = 80%), with only modest parallel changes in serine-phosphorylated AR. In conclusion, the GH-induced activation of signaling pathways, its effects on AR protein in LNCaP cells and the isoform-specific regulation of GHR in prostate cancer patient tissues, suggest that GH, most likely in concert with other hormones and growth factors, may play an important role in progression of human prostate cancer.

Overcoming barriers to teaching the behavioral and social sciences to medical students.

Most U.S. medical schools offer courses in the behavioral and social sciences (BSS), but their implementation is frequently impeded by problems. First, medical students often fail to perceive the relevance of the BSS for clinical practice. Second, the BSS are vaguely defined and the multiplicity of the topics that they include creates confusion about teaching priorities. Third, there is a lack of qualified teachers, because physicians may have received little or no instruction in the BSS, while behavioral and social scientists lack experience in clinical medicine. The authors propose an approach that may be useful in overcoming these problems and in shaping a BSS curriculum according to the institutional values of various medical schools. This approach originates from insights gathered during their attempts to teach various BSS topics at four Israeli medical schools. They suggest that medical faculties (1) adopt an integrative approach to learning the biomedical, behavioral, and social sciences using Engel's "biopsychosocial model" as a link between the BSS and clinical practice, (2) define a hierarchy of learning objectives and assign the highest priority to acquisition of clinically relevant skills, and (3) develop clinical role models through teacher training programs. This approach emphasizes the clinical relevance of the BSS, defines learning priorities, and promotes cooperation between clinical faculty and behavioral scientists.

The CIP (comprehensive integrative puzzle) assessment method.

This paper describes a novel tool for assessment in medical education, the comprehensive integrative puzzle (CIP). The dual scoring system of the puzzle stresses the integrative elements of diagnostic thinking and clinical reasoning, while preserving the ability to discern proficiency in various disciplinary elements. The CIP has the format of an 'extended matching' crossword puzzle. Its answer sheet is a grid comprising rows and columns. The left-hand column contains diagnoses or brief clinical vignettes. To complete the cells of the grid the student is required to match, stepwise, the various 'disciplinary investigations' to the diagnoses or clinical vignettes. When the puzzle is completed each horizontal row reflects a coherent medical case. The completed horizontal rows reflect integrative ability (diagnostic thinking and clinical reasoning) and the vertical columns measure the student's proficiency in interpreting medical history data, physical examination findings, laboratory test results, ECG, imaging, special tests, pathology and pharmacology. The CIP has been well accepted by teachers and students during the last seven years at the Bruce Rappaport Faculty of Medicine in Haifa, and it has favorably affected both student assessment and teaching. The reliability of the test and its validity will be reported separately.

Teaching professionalism with the aid of trigger films.

Medical professionalism includes expert knowledge, self-regulation and fiduciary responsibility to place the needs of patients ahead of the self-interest of physicians. In teaching medical professionalism to our medical students only the behavioural elements are dealt with. One of the challenges facing medical educators today is how medical professionalism can be taught. At the authors' faculty of medicine brief videotapes (trigger films) of amateur actor physician-patient encounters in various clinical settings (taken from genuine encounters) are used as a stimulus for discussion and instruction of medical professionalism. A series of 16 trigger films has been produced that raise many medical professional issues. The films and the issues raised are described in brief. These trigger films are viewed by small groups of medical students together with a physician tutor facilitator at various stages of their studies. It is noteworthy how fast the transition occurs in students, from observing the trigger films in their pre-clinical stage as a client, to observing them in their clinical years from the angle of a provider; from identifying with the patient's concerns to identifying with the physicians' behaviour; from being a critical person to becoming a person who accepts the rules and regulations of the guild. Most probably the power of the teaching of ethical and professional rules is overruled by the power of everyday clinical experience during their clinical clerkships. It is planned to run a series of trigger film sessions with senior and junior physicians of the major clerkships, in an attempt to promote an institutional environment/atmosphere/culture of professional behaviour.

Teaching the cultural dimensions of the patient-physician relationship: a novel approach using didactic trigger films.

The use of trigger films (TFs) for undergraduate teaching is well established in the Technion School of Medicine and elsewhere. These are typically based on a written script highlighting diverse issues within the patient-physician relationship (PPR). We report here on the staging of a filmed script-free encounter between a physician and an actress-patient as a further development of the TF approach. This involved the creation of a clinical interaction in which the patient's revealed cultural background demanded an adaptive response from the physician in order to achieve a stable PPR and to institute effective treatment. Considerable improvisation was thus required. Prior directorial manipulation of the conditions of the interview enhanced the didactic power and goals of the TF. After completion of the filming, the physician and the actress studied the video and then repeated the interview within the same situation free of directorial input. The two sequential videotaped interviews constitute the final product. These TFs appear to carry a wide spectrum of didactic messages at many levels including the need to relate effectively to the cultural aspects in the PPR, and the importance of self-observation as a tool for change and learning.

Development of a physician attributes database as a resource for medical education, professionalism and student evaluation.

In the light of the growing interest in professionalism and non-cognitive attributes in medical education, a focus group (FG) methodology was used to achieve a database of desired physician attributes. Ten FGs, consisting of medical faculty, service heads, residents, general practitioners, students and patients, took place, producing 169 desired attributes; further attributes were derived from a literature search, and the Mission and Vision Statement (MVS) of the authors' medical faculty. A total of 254 separate attributes finally emerged, after a process of combining and collapsing similar items. Attributes appearing with the highest frequency were: honest, empathic, patient, capacity to be an attentive listener, understanding, able to work in a team, intellectual curiosity, egalitarian. The high number of attributes generated in this study provides an indication of what the profession is wanting of itself. This database is multipotential and preliminary in nature and requires further processing before achieving full relevance.