Teaching During the COVID-19 Pandemic: The Experience of the Faculty of Medicine at the Technion-Israel Institute of Technology.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic forced drastic changes in all layers of life. Social distancing and lockdown drove the educational system to uncharted territories at an accelerated pace, leaving educators little time to adjust. OBJECTIVES: To describe changes in teaching during the first phase of the COVID-19 pandemic. METHODS: We described the steps implemented at the Technion-Israel Institute of Technology Faculty of Medicine during the initial 4 months of the COVID-19 pandemic to preserve teaching and the academic ecosystem. RESULTS: Several established methodologies, such as the flipped classroom and active learning, demonstrated effectiveness. In addition, we used creative methods to teach clinical medicine during the ban on bedside teaching and modified community engagement activities to meet COVID-19 induced community needs. CONCLUSIONS: The challenges and the lessons learned from teaching during the COVID-19 pandemic prompted us to adjust our teaching methods and curriculum using multiple online teaching methods and promoting self-learning. It also provided invaluable insights on our pedagogy and the teaching of medicine in the future with emphasis on students and faculty being part of the changes and adjustments in curriculum and teaching methods. However, personal interactions are essential to medical school education, as are laboratories, group simulations, and bedside teaching.

[TEACHING INTERNAL MEDICINE IN THE SHADOW OF THE COVID-19 OUTBREAK - THE EXPERIENCE OF THE TECHNION FACULTY OF MEDICINE].

INTRODUCTION: The clerkship of internal medicine is pursued in the 2nd semester of the 4th year at the Technion Medical School. Following the COVID-19 outbreak, frontal and bedside teaching was interrupted. Therefore, we decided to provide distant teaching until having the opportunity to resume clinical bedside teaching. A team of tutors composed a course of weekly units, each week assigned to a different subject in internal medicine. A total of 120 students were divided into 15 groups of 8 students, each group guided by a personal tutor. The format of each unit included online pretest, clinical virtual cases and two separate 2 hour ZOOM sessions with the tutor. The pretest was based on 1-3 chapters from Harrison's Internal Medicine textbook, 20th edition, and consisted of both clinical reasoning and knowledge questions. During ZOOM sessions with the tutor, the students practiced clinical problem solving. In addition, all the students were granted free access to the commercial "Aquifer" case-based virtual course for more practice. The students' feedback at the end of the learning period revealed that, although frustrated in being away from the clinics, the overall level of satisfaction from the course was good (rated 5 or 4/5 by 65% of responders) and the time was used efficiently. In conclusion, the students received a positive proactive learning experience of both theoretical aspects and clinical reasoning skills in internal medicine. There is no doubt that bedside teaching in medicine is invaluable and can't be replaced by any other means, however, given the circumstances, our format provided a reasonable temporary alternative.

Medical students' attitudes towards participating in a palliative medicine course: A new specialty in Israel.

BACKGROUND: Palliative medicine is a growing field in Israel, and its training program is still in process. The current study aimed to evaluate students' attitudes regarding a course in palliative care established in a division of oncology. METHOD: Some 45 medical students in their 5th to 6th years participated in a one-week course on palliative care. At the end of each training week, students were asked to complete a questionnaire, evaluating their attitudes regarding different aspects of the program content, such as its importance and relevance to their training as physicians, as well as the contribution of specific parts of the program to their knowledge regarding palliative care. RESULTS: The overall satisfaction of the 45 students was high. The most contributory parts of the course were the multidisciplinary team and the complementary and alternative medicine. Participating in the staff meetings and accompanying physicians in their daily work were scored as the least contributory parts.Significance of resultsThis preliminary study demonstrated students' overall high satisfaction with the newly established palliative care course and their need for more practical skills. Future studies should investigate and evaluate educational programs in palliative care in order to establish suitable training for medical students.

[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.

[Medical students' views on the use of virtual patients for teaching and assessment of clinical knowledge and reasoning].

BACKGROUND: Computerized cLinical cases ["virtual patient" (VP)] provide a useful teaching and assessment tool for clinicaL knowledge and skiLLs. However, the attitude of medical students toward this new modality needs to be evaluated. We examined students' acceptance of a web-based VP system that was deveLoped in the Technion Faculty of Medicine for teaching and assessment purposes. The VP system enables free conversation (in writing) for history taking and listing of disease symptoms. It aLso depicts images and audio-videos of heart and lung sounds, and enables users to order Laboratory and imaging tests. The system was designed to be learnt without instructors and to provide feedback online. Therefore, the process of Learning and practicing with the VP system was performed by the students at home, during their free time. METHODS: At the end of the clinical introductory course to internal medicine, students (n=91) were asked to complete questionnaires and rate multiple aspects of the VP system. RESULTS: Student acceptance of this web-based modality was high: over 95% fully or partially accepted that the VP practice system facilitates Learning the approach to diseases they were not exposed to during the course, practicing differential diagnosis, and improving their knowledge, clinicaL skills and reasoning. A similar percentage of the students agreed that the VP exam assessed their clinical knowledge and comprehension adequately, correctly and objectively. CONCLUSIONS: These results document high acceptance of web-based instruction and assessment by medical students. However, many students expect that a clinical course should also include bed-side assessment.

Long experience with a web-based, interactive, conversational virtual patient case simulation for medical students' evaluation: comparison with oral examination.

Virtual patients (VP) have been advocated as reliable tools for teaching and evaluating clinical skills and competence. We have developed an internet-based, OSCE-like, conversational VP system designed both for training and assessment of medical students. The system, that encompasses complete patient management from H&P to diagnostic procedures and treatment, has now been used regularly during the clerkship of internal medicine. The present article describes the system and compares assessments undertaken with the VP-system over the last five years, to traditional bed-side oral exams. All students practiced on their own exercise VP cases, while preparing for the final exam. A total of 586 students were evaluated simultaneously with both assessment modalities. The αCronbach of the VP exam averaged 0.86. No correlation was found between the grades obtained in the two exams, indicating that the VP exam evaluated different parameters than those assessed by the examiners in the oral examinations. We conclude that a VP system can be utilized as a valid and reliable examination tool. It is also most useful for independent training by students during their ward-based learning, as well as when not studying in classes, wards or clinics, when social distancing is required.

Survey of faculty development in four Israeli medical schools: clinical faculty development is inadequate and clinical teaching is undervalued in Israeli faculties of medicine.

BACKGROUND: Teaching medical students is a central part of being a doctor, and is essential for the training of the next generation of physicians and for maintaining the quality of medicine. Our research reviews the training that physicians in Israel receive as teachers of clinical clerkships, and their thoughts regarding teaching students. The importance of faculty development cannot be overstated, for securing quality medicine and physician empowerment. METHODS: This study was based on a survey conducted among physicians teaching at Israeli medical schools. The survey was conducted using an online questionnaire sent to clinical teachers according to lists received from the teaching units of the faculties, department heads, and other clinical teachers. Participation in the study was anonymous. FINDINGS: Of 433 invited physicians, 245 (56%) from three departments (internal medicine, paediatrics, obstetrics and gynaecology) of four faculties of medicine in Israel, out of five total, completed the questionnaire. Only 35% of the physicians reported having received training for their role as teachers, most of these participated in a short course of up to 2 days. There were significant differences between the Technion and the other schools. Technion teachers without academic appointment had higher rates of pedagogic training. The same was true in regard to Technion teachers, either residents or young specialist. Significant gaps were reported between the content covered in the training and the topics the doctors felt they would want to learn. The clinicians who participated in the survey expressed that clinical teaching was less valued and more poorly remunerated than research, and that improved compensation and perceived appreciation would likely improve the quality of clinical teaching. CONCLUSIONS: Of the one-third of the physicians surveyed who had received some training in clinical teaching, the training was perceived as inadequate and not aligned with their needs. There was a significant difference in rates of pedagogic training between the Technion and other medical schools. In addition, most clinical teachers surveyed felt that teaching students is inadequately valued. Due to its focus on just three disciplines, and higher relative number participants from the Technion faculty of medicine, our survey may not fully represent the activities of the faculties of medicine in Israel. Nevertheless, given the importance of clinical teaching of medical students, our findings argue for increasing faculty development and educational training of physicians in clinical settings, for recognizing the importance of teaching in academic and professional promotion processes.

From COVID-19 adversity comes opportunity: teaching an online integrative medicine course.

BACKGROUND: We examine the impact of a 5-day online elective course in integrative medicine (IM) taking place during the COVID-19 pandemic, attended by 18 medical students from two faculties of medicine in Israel. METHODS: The course curriculum addressed effectiveness and safety of IM practices highlighting supportive and palliative care, demonstrated the work of integrative physicians (IPs) in designing patient-tailored treatments and taught practical skills in communication regarding IM. Group discussions were conducted via Zoom with 32 physicians, healthcare practitioners and IM practitioners working in integrative academic, community and hospital-based settings, in Israel, Italy, UK and Germany. An 18-item questionnaire examined student attitudes and perceived acquisition of skills for implementing what was learned in clinical practice. Student narratives were analysed using ATLAS.Ti software for systematic coding, identifying barriers and advantages of the online learning methodology. RESULTS: Students reported a better understanding of the benefits of IM for specific outcomes (p=0.012) and of potential risks associated with these therapies (p=0.048). They also perceived the acquisition of skills related to the IM-focused history (p=0.006), learnt to identify effectiveness and safety of IM treatments (p=0.001), and internalised the referral to IPs for consultation (p=0.001). Student narratives included reflections on the tools provided during the course for assessing effectiveness and safety, enhancing communication with patients, enriching their patient-centred perspective, raising awareness of available therapeutic options, and personal and professional growth. CONCLUSIONS: Online clinical electives in IM are feasible and can significantly increase students' awareness and modify attitudes towards acquirement of patient-centred perspectives.

[Strive, plan and reach the "Summit": the Faculty Development Program at the Ruth & Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology].

BACKGROUND: In recent years, faculty development has turned into a central component of medical education and a primary instrument in qualifying physicians to be teachers and educators. The faculty development program at the Ruth & Bruce Rappaport Faculty of Medicine ("Summit" program) was established in order to improve teaching of the clinical professions, to create a community of medical teachers and educators and to develop leadership in medical education within the Faculty of Medicine. OBJECTIVE: This article aims to describe the design, implementation and evaluation of the faculty development program in the Technion's Faculty of Medicine. METHODS: The program was designed for a group of 20 clinical teachers, of various clinical professions, who had gained at least one year of undergraduate teaching experience and wished to develop a career in medical education. The program included seven monthly, eight-hour meetings throughout the academic year. Learning was based on small group discussions, interactive exercises, role-plays and simulations, self-directed reading and reflective writing. At the end of the final meeting, participants completed an evaluation form. RESULTS: Seventeen of the 20 participants (85%) graduated and received certificates. Learners' overall satisfaction was high. Graduates expressed high motivation to practice medical education within the Faculty of Medicine and reported that they gained new knowledge in medical education and skills regarding various aspects of teaching and learning, such as formulation of learning objectives, designing role plays, and providing effective feedback. CONCLUSIONS: The "Summit" program is an innovative initiative in the field of medical education in Israel. The program had a significant impact on participants' knowledge, teaching skills and attitudes. In order to ensure implementation of the acquired tools and skills, its shortterm and long-term effects on teaching behavior and the learning climate have yet to be demonstrated. In addition, it is necessary to check if the program affected the faculty as an organization, promoted changes in curricula, teaching and evaluation methods.

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.

Residual effects of daytime administration of melatonin on performance relevant to flight.

There is a general consensus that melatonin possesses time-dependent hypnotic effects, but there is no information yet whether it has residual effects on neurobehavioral performance, especially after daytime administration. In the present study we investigated the possible residual effects of 3 mg melatonin on performance relevant to flight and on subjective feelings of sleepiness, arousal, activation and affect after a daytime nap, as a function of nap length. Fifteen reserve pilots of the Israeli Air Force participated in the study. The experiment consisted of four sessions during which either melatonin or placebo was administered at 16:00 h. In two conditions, subjects were allowed to sleep for 2 h (17:00-19:00 h) whereas in the other two only a 0.5-h nap was allowed. After the naps they started performing a flight simulator task every 2 h. Sleep efficiency significantly increased and sleep latency significantly decreased in both melatonin conditions compared to placebo. Flight performance was only mildly affected in the 0.5-h nap condition. Subjective assessment of sleepiness significantly differed between the two treatment conditions, only in the 0.5-h nap condition. Subjects felt sleepier 2-4 h after melatonin administration. To conclude, our data suggest that administration of melatonin before a brief daytime nap (about 0.5 h) may be associated with mild residual effects on psychomotor performance and may significantly affect subjective feeling of sleepiness for 2-4 h.

Melatonin administration alters semen quality in healthy men.

The role of melatonin in the regulation of reproduction in humans is unknown. We conducted a 6-month, double-blind, crossover study of a daily treatment dose of 3 mg melatonin or placebo given orally at 1700 hours in 8 healthy men. Semen quality (concentration, motility, and morphology), serum and seminal plasma 17-beta-estradiol (E(2)), testosterone, melatonin, and serum gonadotropin levels were determined every 3 months throughout the study. In 6 men, there was no change in semen quality or in serum and seminal plasma hormone levels during the study period. In 2 men, during the melatonin treatment period, sperm concentration decreased to 3 x 10(6)/mL and 12 x 10(6)/mL, and motility declined to 32% and 30%. These coincided with a decline in seminal plasma and serum E(2) levels and with an increase in testosterone:E(2) ratios. Six months after the cessation of melatonin, sperm concentration and motility were normal in 1 man but remained abnormal in the other one with a still elevated testosterone:E(2) ratio. Serum gonadotropin levels were unchanged during the study in all 8 men. Our preliminary observations suggest that long-term melatonin administration is associated with decreased semen quality in a number of healthy men, probably through the inhibition of aromatase at the testicular level.

The effect of pyridoxine administration on melatonin secretion in normal men.

OBJECTIVES: To determine pineal response to pyridoxine in normal men. MATERIAL AND METHODS: Twelve healthy men were given orally pyridoxine (100 mg) or placebo at 1700h. Serum melatonin levels were determined every 30 minutes with simultaneous measurement of core body temperature between 1700h to 0300h. Polysomnographic sleep recordings were performed between 1800h to 2000h. RESULTS: Serum melatonin levels after both placebo and pyridoxine showed a nocturnal rise occurring at 22:10+/-1:22h and 22:24+/-1:09h, respectively. The melatonin onset, peak, mean and area under the curve (AUC) values after pyridoxine (3.2+/-1.6 pg/ml, 47.2+/-22.6 pg/ml, 31.5+/-11.0 pg/ml and 173.5+/-138.4 pg/ml x min, respectively) were similar to the values after placebo administration (4.7+/-1.6 pg/ml, 53.9+/-26.0 pg/ml, 37.2+/-2.8 pg/ml and 205.3+/-137.8 pg/ml x min, respectively). CBT revealed a significant nocturnal decline but without significant difference between pyridoxine and placebo. Sleep amount and architecture were similar after the two treatments. CONCLUSIONS: In adult man, the oral administration of 100 mg-pyridoxine during the evening hours has no effect on melatonin secretion nor does it alter CBT or sleep quality.

Can outcome-based continuing medical education improve performance of immigrant physicians?

INTRODUCTION: Immigrant physicians are a valued resource for physician workforces in many countries. Few studies have explored the education and training needs of immigrant physicians and ways to facilitate their integration into the health care system in which they work. Using an educational program developed for immigrant civilian physicians working in military primary care clinics at the Israel Defence Force, we illustrate how an outcome-based CME program can address practicing physicians' needs for military-specific primary care education and improve patient care. METHODS: Following an extensive needs assessment, a 3-year curriculum was developed. The curriculum was delivered by a multidisciplinary educational team. Pre/post multiple-choice examinations, objective structured clinical examinations (OSCE), and end-of-program evaluations were administered for curriculum evaluation. To evaluate change in learners' performance, data from the 2003 (before-program) and 2006 (after-program) work-based assessments were retrieved retrospectively. Change in the performance of program participants was compared with that of immigrant physicians who did not participate in the program. RESULTS: Out of 28 learners, 23 (82%) completed the program. Learners did significantly better in the annual post-tests compared with the pretests (p <.01) and improved their OSCE scores (p <.001). Most program graduates (90%) rated overall satisfaction as very good or excellent. In comparison with nonparticipants, program graduates performed better on work-based assessments (Cohen's d =.63). DISCUSSION: Our intensive, outcome-based, longitudinal CME program has yielded encouraging results. Other medical educators, facing the challenge of integrating immigrant physicians to fit their health care system, may consider adapting our approach.