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.

[ON THE EQUATOR].

INTRODUCTION: Elective clerkships in low income countries have been an integral part of the curriculum in the majority of medical schools worldwide. These programs expose students to global challenges, to a diversity of cultures and healthcare systems, and have been shown to improve medical knowledge, as well as clinical and communication skills. In 2018 and 2019, the Faculty of Medicine at the Technion, in cooperation with the Department for Infectious Diseases in the Rambam Health Care campus and the "Brit Olam" nonprofit organization, offered a clinical clerkship in Kiboga hospital, Uganda. The elective took place in a public governmental hospital located in one of the poorest districts of Uganda. During a three-week period, the students accompanied by Israeli and Uganda tutors, participated in clinical rounds and other clinical activities in various departments of the hospital. This manuscript, describes the students' experiences in Kiboga. During the short elective, students had a unique opportunity to observe a different culture, immerse in a completely different healthcare system, learn about how a detailed medical history and a thorough physical examination can lead to diagnosis (without extensive diagnostic tests), and closely observe ethical challenges and difficult clinical decisions. The elective helped students develop personally and professionally and solidify their commitment to medicine. Currently, in Israeli medical schools, there are a few programs which expose students to medicine in low-resource countries. We believe that expanding the understanding of Global Health through courses and overseas opportunities in long-term partnerships, can improve the students' medical education.

A Simulator for Measuring Forces During Surgical Knots.

In this study new metrics were developed for assessing the performance of surgical knots. By adding sensors to a knot tying simulator we were able to measure the forces used while performing this basic and essential skill. Data were collected for both superficial tying and deep tying of square knots using the one hand and two hands techniques. Participants used significantly more force when tying a deep knot compared to a superficial knot (3.79N and 1.6N respectively). Different patterns for upward and downward forces were identified and showed that although most of the time upward forces are used (72% of the time), the downward forces are just as large. These data can be crucial for improving the safeness of knot tying. Combing these metrics with known metrics based on knot tensiometry and motion data may help provide feedback and objective assessment of knot tying skills.

Rapid HIV Screening in an Urban Jail: How Testing at Exit With Linkage to Community Care Can Address Perceived Barriers.

Despite recommendations from the CDC, only 36 % of jails offer routine HIV screening to inmates. Our purpose was to explore the feasibility of rapid HIV testing at release from an urban jail, and to identify potential barriers to this process. This project was incorporated into an established partnership between the jail, local academic medical center, and local public health department. We offered rapid HIV testing at the time of release to 507 jail inmates over a 7 week period of 2013. Three hundred and two (60 %) inmates elected testing. All participating inmates received individual test counseling, HIV prevention education, and linkage to care in the community prior to release. All tested inmates received results before release; one inmate screened positive for HIV and was linked to care. Previous HIV testing was the most frequently cited reason given (60 %) among the 205 inmates who declined at the time of the study. Utilizing the partnership between the jail, public health, and an academic medical center, we found that rapid HIV testing at exit was feasible and acceptable in this urban jail setting and could provide immediate linkage to care for those in need.

A Selected Review of the Mortality Rates of Neonatal Intensive Care Units.

INTRODUCTION: Newborn babies in need of critical medical attention are normally admitted to the neonatal intensive care unit (NICU). These infants tend to be preterm, have low birth weight, and/or have serious medical conditions. Neonatal survival varies, but progress in perinatal and neonatal care has notably diminished mortality rates. In this selected review, we examine and compare the NICU mortality rates and etiologies of death in different countries. METHODS: A literature search was conducted in Ovid MEDLINE, OLDMEDLINE, EMBASE Classic, and EMBASE. The primary endpoint was the mortality rates in NICUs. Secondary endpoints included the reasons for death and the correlation between infant age and mortality outcome. For the main analysis, we examined all infants admitted to NICUs. Subgroup analyses included extremely low birth weight infants (based on the authors' own definition), very low birth weight infants, very preterm infants, preterm infants, preterm infants with a birth weight of ≤1,500 g, and by developed and developing countries. RESULTS: The literature search yielded 1,865 articles, of which 20 were included. The total mortality rates greatly varied among countries. Infants in developed and developing countries had similar ages at death, ranging from 4 to 20 days and 1 to 28.9 days, respectively. The mortality rates ranged from 4 to 46% in developed countries and 0.2 to 64.4% in developing countries. CONCLUSION: The mortality rates of NICUs vary between nations but remain high in both developing and developed countries.

Comparison of Opt-In Versus Opt-Out Testing for Sexually Transmitted Infections Among Inmates in a County Jail.

A majority of jails in the United States rely on an opt-in (voluntary) rather than opt-out (universal) approach to testing for sexually transmitted infections (STIs). This study compares an opt-out approach at intake to opt-in testing during incarceration and estimates the prevalence of common STIs among jail inmates. Data derive from a universal intake pilot testing program (n = 298) and an established, student-led voluntary testing program (n = 1,963), respectively. The adjusted prevalence as well as the odds of testing positive for chlamydia were significantly higher in the opt-out program (p = .025 and .008, respectively) than the opt-in program but not for gonorrhea (p = .402 and .300, respectively). These results demonstrate the potential public health benefit of implementation of universal STI testing of jail inmates.

Knowledge, attitudes, and practices for cervical cancer screening among the Bhutanese refugee community in Omaha, Nebraska.

Cervical cancer is the second most common cause of cancer mortality among women with the vast majority of patients in developing countries. Bhutanese refugees in the United States are from South Central Asia, the 4th leading region of the world for cervical cancer incidence. Over the past few years, Bhutanese refugees have increased significantly in Nebraska. This study evaluates current knowledge of cervical cancer and screening practices among the Bhutanese refugee women in Omaha, Nebraska. The study aimed to investigate cervical cancer and screening knowledge and perceptions about the susceptibility and severity of cervical cancer and perceived benefits and barriers to screening. Self-administered questionnaires and focus groups based on the Health Belief Model were conducted among 42 healthy women from the Bhutanese refugee community in Omaha. The study revealed a significant lack of knowledge in this community regarding cervical cancer and screening practices, with only 22.2 % reporting ever hearing of a Pap test and 13.9 % reporting ever having one. Only 33.3 % of women were in agreement with their own perceived susceptibility to cervical cancer. Women who reported ever hearing about the Pap test tended to believe more strongly about curability of the disease if discovered early than women who never heard about the test (71.4 vs. 45.0 %, for the two groups. respectively). Refugee populations in the United States are in need for tailored cancer education programs especially when being resettled from countries with high risk for cancer.

Voluntary STD testing and treatment program at a metropolitan correctional facility: evaluation of test acceptability and associated risk factors.

Few studies have addressed challenges of diagnosis and treatment of sexually transmitted diseases (STDs) within correctional facilities. Initiatives that screen all inmates can be cost-prohibitive, while symptom-based screening undoubtedly fails to recognize significant numbers of asymptomatically infected persons. This study discusses a voluntary STD screening and treatment program developed at the Douglas County (Nebraska) Department of Corrections where student volunteers interviewed, screened, and educated 456 inmates. Inmate urine samples and interview responses about risk behaviors and motivators for participation in the screening program were analyzed. The results support the ongoing project method to screen and treat inmates in the community correctional facility. Risk factor analysis suggests that targeted testing and treatment efforts may have a role in providing cost-effective care for STD among the incarcerated population.

Commentary: educating the present and future health care workforce to provide care to populations.

The crisis of the rising cost of health care in the United States is stimulating major changes in the way care is being delivered. New models such as patient-centered medical homes and accountable care organizations are being developed with the expectation that health care professionals will address and improve the health of populations. Electronic health records and interprofessional teams will be critical to achieving the goal of better health. It is now time to bring together educators and clinicians at academic health centers, public health educators and practitioners, along with researchers, representatives from the health care delivery and financing systems, and community partners to reengineer health professions education to prepare health professions students for the health care system of the future.

An anatomy of conflicts in primary care encounters: a multi-method study.

BACKGROUND: Medical consultations are replete with conflicts, particularly in the current era of explicit and implicit rationing practices in health care organizations. Although such conflicts may challenge the doctor-patient relationship, little is known about them or their consequences. AIMS: To systematically describe the nature of doctor-patient conflicts in medical encounters and the strategies physicians use when faced with conflicts. METHODS: Analysis of 291 videotaped routine encounters with 28 general practitioners, using a novel adaptation of the Roter interaction analysis system software, provided quantitative empirical data on the conflicts and on the communication process. Seven focus groups (56 GPs) provided qualitative insights and guided the analysis. RESULTS: Conflicts were identified in 40% of consultations; 21% of these were related to the rationing of health care resources. In conflictual encounters, both the opening and closing phases of the encounter were shorter than in non-conflictual encounters. In coping with resource rationing, the commonest strategy was to accept the dictates of the system without telling the patients about other options. When conflict of this type occurred, doctors showed more opposition to the patients rather than empathy. CONCLUSIONS: Doctors often face conflicts in their routine work, but resource-related conflicts are especially difficult and expose the dual loyalties of the doctor to the patient and to the system. Insights derived from this research can be used to design training interventions that improve doctors' efficacy in coping with conflicts and ultimately allow them to provide better patient care.

From professional silos to interprofessional education: campuswide focus on quality of care.

OBJECTIVES: The Institute of Medicine called for the integration of interprofessional education (IPE) into health professions curricula, in order to improve health care quality. In response, we developed, implemented, and evaluated a campus wide IPE program, shifting from traditional educational silos to greater collaboration. METHODS: Students (155) and faculty (30) from 6 academic programs (nursing, medicine, public health, allied health, dentistry, and pharmacy) engaged with a university hospital partner to deliver this program. The content addressed principles of IPE, teamwork development and 2 common quality care problems: hospital-acquired infections and communication errors. Pre-/post-surveys, the Readiness for Interprofessional Learning Scale, and the Interprofessional Education Perception Scale, were used for descriptive assessment of student learning. RESULTS: Students demonstrated increased understanding of health care quality and interprofessional teamwork principles and reported positive attitudes toward shared learning. While responses to the Readiness for Interprofessional Learning Scale grew more positive after the program, scores on the Interprofessional Education Perception Scale were more homogeneous. Both students and faculty highly evaluated the experience. CONCLUSION: This program was a first step in preparing individuals for collaborative learning, fostering awareness and enthusiasm for IPE among students and faculty, and demonstrating the feasibility of overcoming common barriers to IPE such as schedule coordination and faculty buy-in.

Teaching complementary medicine at an academic oncology department.

BACKGROUND: The increased use of complementary and alternative medicine (CAM) by patients with cancer is a significant phenomenon in cancer care and suggests the need for increased knowledge by clinicians of these therapies. METHODS: Aiming at bridging the gap in knowledge of the philosophy and practice of major CAM modalities in cancer care, an elective course was offered to physicians and nurses in a large academic center. RESULTS: The course also aimed at providing the tools necessary to establish open and trusting clinician-patient dialogue regarding CAM. CONCLUSIONS: Exposure to the course was successful in improving knowledge and attitudes.

Promoting lifestyle self-awareness among the medical team by the use of an integrated teaching approach: a primary care experience.

OBJECTIVES: Healthy lifestyle is recommended in clinical guidelines for the prevention and treatment of chronic diseases such as cardiovascular disease and diabetes. Research previously identified a gap between lifestyle recommendations and their implementation in clinical practice. In this paper, we describe a pilot educational program aimed to promote providers' awareness of their own lifestyles, and to explore whether increased personal awareness enhances providers' willingness to engage in lifestyle-change discussion with patients. METHODS: Two primary-care urban clinics in Northern Israel participated in the program, which consisted of a series of six biweekly educational sessions, each lasting 2-4 hours. Each session included both knowledge-based and experiential learning based on complementary medicine modalities. Surveys at the end of the program and a year later provided the program evaluation. RESULTS: Thirty-five personnel participated in the program. Thirteen (13) of the 20 participants (65%) reported an attitude change regarding eating habits after the program. At 1-year follow up, 24 of the 27 respondents (89%) stated that they were more aware of their eating habits and of their physical activity compared with precourse status. Twenty-three (23) of 27 respondents (85%) stated that after the program they were better prepared to initiate a conversation with their patients about lifestyle change. CONCLUSIONS: An integrated educational approach based on knowledge-based and complementary and alternative medicine experiential modalities, aimed to facilitate self-awareness, may enhance learners' attitude change. The findings demonstrate readiness of learners to reexamine their lifestyles. Increased self-awareness helped participants to make a positive attitude change regarding eating habits and physical activity and was associated with participants' increased engagement in lifestyle-change discussions with patients. The teaching approach had longstanding effect, noted in the one-year follow-up.

Electronic medical record use and physician-patient communication: an observational study of Israeli primary care encounters.

OBJECTIVES: Within the context of medical care there is no greater reflection of the information revolution than the electronic medical record (EMR). Current estimates suggest that EMR use by Israeli physicians is now so high as to represent an almost fully immersed environment. This study examines the relationships between the extent of electronic medical record use and physician-patient communication within the context of Israeli primary care. METHODS: Based on videotapes of 3 Israeli primary care physicians and 30 of their patients, the extent of computer use was measured as number of seconds gazing at the computer screen and 3 levels of active keyboarding. Communication dynamics were analyzed through the application of a new Hebrew translation and adaptation of the Roter Interaction Analysis System (RIAS). RESULTS: Physicians spent close to one-quarter of visit time gazing at the computer screen, and in some cases as much as 42%; heavy keyboarding throughout the visit was evident in 24% of studied visits. Screen gaze and levels of keyboarding were both positively correlated with length of visit (r = .51, p < .001 and F(2,27) = 2.83, p < .08, respectively); however, keyboarding was inversely related to the amount of visit dialogue contributed by the physician (F(2,27) = 4.22, p < .02) or the patient (F(2,27) = 3.85, p < .05). Specific effects of screen gaze were inhibition of physician engagement in psychosocial question asking (r = -.39, p < .02) and emotional responsiveness (r = -.30, p < .10), while keyboarding increased biomedical exchange, including more questions about therapeutic regimen (F(2,27) = 4.78, p < .02) and more patient education and counseling (F(2,27) = 10.38, p < .001), as well as increased patient disclosure of medical information to the physician (F(2,27) =3.40, p < .05). A summary score reflecting overall patient-centered communication during the visit was negatively correlated with both screen gaze and keyboarding (r = -.33, p < .08 and F(2,27) = 3.19, p < .06, respectively). DISCUSSION: The computer has become a 'party' in the visit that demanded a significant portion of visit time. Gazing at the monitor was inversely related to physician engagement in psychosocial questioning and emotional responsiveness and to patient limited socio-emotional and psychosocial exchange during the visit. Keyboarding activity was inversely related to both physician and patient contribution to the medical dialogue. Patients may regard physicians' engrossment in the tasks of computing as disinterested or disengaged. Increase in visit length associated with EMR use may be attributed to keyboarding and computer gazing. CONCLUSIONS: This study suggests that the way in which physicians use computers in the examination room can negatively affect patient-centered practice by diminishing dialogue, particularly in the psychosocial and emotional realm. Screen gaze appears particularly disruptive to psychosocial inquiry and emotional responsiveness, suggesting that visual attentiveness to the monitor rather than eye contact with the patient may inhibit sensitive or full patient disclosure. PRACTICAL IMPLICATIONS: We believe that training can help physicians optimize interpersonal and educationally effective use of the EMR. This training can assist physicians in overcoming the interpersonal distancing, both verbally and non-verbally, with which computer use is associated. Collaborative reading of the EMR can contribute to improved quality of care, enhance the decision-making process, and empower patients to participate in their own care.

Specific delivery of corroles to cells via noncovalent conjugates with viral proteins.

PURPOSE: Corroles are amphiphilic macrocycles that can bind and transport metal ions, and thus may be toxic to cells. We predicted that anionic corroles would poorly enter cells due to the negatively charged cell membrane, but could be ideal tumor-targeted drugs if appropriate carriers enabled delivery into tumor cells. In this work, we test the hypothesis that recombinant cell penetrating proteins of the adenovirus (Ad) capsid form noncovalent conjugates with corroles to facilitate target-specific delivery and cell death. METHODS: Corroles mixed with recombinant proteins were tested for conjugate assembly, cell penetration, stability, targeted binding, and cell killing in vitro. RESULTS: Sulfonated corroles entered cells only with carrier proteins, and formed stable complexes with recombinant Ad capsid proteins. ErbB receptor-targeted conjugates were cytotoxic to ErbB2-positive but not ErbB2-negative breast cancer cells, whereas molar equivalents of free corrole had no effect on these cells. CONCLUSIONS: Sulfonated corroles are cytotoxic to ErbB2-positive breast cancer cells when delivered by a targeted cell penetrating protein. The relatively low dose required to accomplish this compared to untargeted compounds suggests that corroles may lend themselves to targeted therapy. Importantly, the amphiphilicity of corroles enables a unique approach to bioconjugate formation whereby the carrier and drug form a stable complex by noncovalent assembly.

The influence of offering free transdermal nicotine patches on quit rates in a local health department's smoking cessation program.

Nicotine replacement therapy (NRT) has added to the menu of options available to assist cigarette smokers in quit attempts, but cost remains a barrier to access. A quasi-experimental study was carried out to compare quit rates and continuous abstinence from smoking before (n=601) and after (n=311) free nicotine patches were offered to smokers who participated in the Washington County (Maryland) Health Department's "Stop Smoking for Life" group behavioral cessation program. After free NRT was offered, the quit rates upon completion of the program increased from 38% to 65% [difference 27%; 95% confidence limits (CL) 21%, 34%]. The difference in continuos abstinence from smoking between the two groups was no longer statistically significant after 6 months of follow-up, reflecting the more rapid rate of reversion to smoking that occurred during the 18-month follow-up period among the free NRT group who had quit [adjusted rate ratio (RR) 1.35; 95% CL 1.03, 1.78]. Enrollment during the first 18 months after free NRT was 37% greater than the program's first 18 months (P=.08). In conclusion, adding free nicotine patches to a smoking cessation program was associated with increased program enrollment and significantly increased short-term-but not long-term-quit rates. The rapid reversion to smoking in the group who received free nicotine patches could potentially be obviated if participants extend their use of nicotine patches after the free 6-week supply is exhausted.

Approaching complementary and alternative medicine use in patients with cancer: questions and challenges.

Complementary and alternative medicine (CAM) is becoming a significant factor in the arena of cancer care. There is an increasing body of research along with widespread popularity and use by patients with cancer. This article reviews current knowledge about the worldwide use of CAM in the treatment of cancer and patients' motives and reasoning for this use. Clinical research in CAM cancer treatments and physicians' attitudes toward this popular trend among patients with cancer are discussed as well. The physician-patient communication and its relevance to CAM use is emphasized. A step approach is suggested for primary care physicians including the discussion of CAM in the management of cancer in order to enrich the physician-patient dialogue and improve the quality of the clinical encounter.